Cracked-tooth syndrome
Caryl E. Cameron,* D.D.S., M.S., Chicago
The most important factor in diagnosis
of a cracked tooth is awareness that these
cracks occur. The predominant symptom
is discomfort to pressure and thermal
changes. Deeper cracking can be pre­
vented.
Bicuspids and molars frequently are frac­
tured and split mesiodistally into buccal
and lingual fragments. Diagnosis is obvi­
ous, and treatment is by extraction. T o
prevent these fractures in teeth severely
weakened by deep caries or root canal
therapy, the cusps should be routinely
protected with overlays or complete ve­
neer crowns. In fact, failure to do this is
inadequate dental service.
The problem is the early diagnosis of
a crack in a vital tooth and its treatment
to prevent further splitting. Teeth do
crack; there are symptoms, and early rec­
ognition will help protect these teeth also.
The following observations led to the con­
clusion that there is a cracked-tooth
syndrome.
The first observation came through a
patient’ s complaint of pain on application
of cold or pressure to the tooth. This hap­
pened in a molar in which a simple mesio-
occlusal inlay had been placed recently.
The complaints were dismissed as normal
sensitivity to a new inlay. Later complaints
of sensitivity to pressure brought occlusal
adjustment; the inlay was thought to
have been “ high.” A year later, a distal
cusp broke off, and the patient said she
was finally comfortable. It probably had
been cracked all that time. This recalled
similar incidents in which teeth painful
on chewing were relieved when a cusp
broke away, even though sensitive dentin
then was exposed. In these fractures,
there was no pulp involvement, and the
patient could chew comfortably on that
side again.
The second observation came from
curiosity as to why some posterior teeth
had abscessed. There was no periodontal
disease, only small shallow restorations,
and the teeth with large restorations had
no pulp exposures. Yet the pulp had died;
there was roentgenographic evidence of
rarefaction at the apex, and the tooth was
extracted (Fig. 1).
When examined with a hand lens,
many o f these teeth were found to have
cracks extending into the cementum from
the marginal ridge or gingival margin of
the proximal restoration. The cracks were
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Fig . I • Sm all shallow restoration with no obvious
reason fo r rad iolucent region a t apex. C ra c k is
not seen roentg eno g rap hically
either mesial, distal or both. On section­
ing, the crack extended into the pulp, but
the tooth had not fractured (Fig. 2 ).
When the patients were questioned, some
gave histories o f pain; others remembered
nothing. Several mentioned having had
occlusal adjustment o f that tooth.
A third observation concerned three
patients I treated ten years ago. They had
fractured teeth which had to be ex­
tracted. Shortly thereafter, each com ­
plained of pain in another tooth. All
diagnosed the crack themselves since the
pain was similar to that in the other tooth
Fig. 2 • Three ty p ica l cracked teeth
R ig h t:U p p e r bicuspid
before it was extracted. These latter
teeth were covered with complete veneer
crowns and still are giving good service
ten years later. Fractures had been pre­
vented.
H IS T O R Y
In the literature, much has been written
about completely fractured teeth, but
there are only a few references to cracks
or incomplete fractures.
In 1954, Gibbs1 described the incom­
plete fracture as “ cuspal fracture odon­
talgia,” and he discussed cause, diagnosis,
and treatment. No case histories were pre­
sented. Mellion2 in 1956 described the
history, symptoms and treatment o f a
fractured cusp. Thom a3 described “ fis­
sured fractures” and stated that, if deep,
fractures may allow bacteria to invade
the pulp. He also stated4 that these “ frac­
tures in posterior teeth caused by occlusal
force are not always easily detected.”
Ritchie and others5 in 1957 reported 22
instances of pulpitis resulting from incom­
plete tooth fracture. All but one had
restorations of soft cast gold. The authors
observed the symptoms and the progres­
sion through pulpitis and endodontic
therapy to complete veneer crowns. Some
vital teeth were kept vital by early recog­
nition and protection.
a fte r sectioning. L e ft:U p p e r molar. M id d le :L o w e r molar.
Fig. 3 • C ra c k extending from g ing ival m argin of
restoration ap ically. T o p :G o ld inlay. M id d le :
A m alg am . B o tto m :H ig h e r m agnification o f am al­
gam shown above

Sutton6 in 1962 described “ greenstick

fracture of the tooth crown.” Eight cases
o f cracked cusps were treated by remov­
ing the fractured tooth substance and re­
storing the tooth. In each, the fracture
line went from the pulpal wall of an old
cavity preparation out toward the cemen-
toenamel junction. He and Ritchie agreed
that an awareness of the problem is the
most important factor in diagnosis. Sutton
considered the greenstick fracture an in­
termediate stage o f fracture between the
development of a crack and the fracture
o f the tooth. H e stated that they are
caused by trauma from lateral forces in
teeth weakened by cavities.

D IA G N O S IS

Although many dentists are aware of

cracked teeth, it seldom is covered in
textbooks and has not been brought to the
attention o f students. The most important
factor in its diagnosis is an awareness of
the problem. A well-known maxillofacial
surgeon and diagnostician7 reported that
patients with cracked teeth frequently
were sent to him as diagnostic problems.
The patients were in pain; pulps were
vital; there were no cavities, and the res­
torations were good. He and others have
helped collect 50 examples o f cracked
posterior teeth.
Symptoms are not always clear-cut, nor
is the tooth always easily identifiable.
There may be vague pains when the teeth
are heated or cooled and discomfort in
chewing, and the patient may favor the
affected side. The most common com ­
plaint is pain to pressure. If the patient
cannot localize the pain, tapping the
teeth often will help him do so. The vari­
ous cusps should be tapped in all direc­
tions. Sometimes by biting on a wooden
toothpick the patient can demonstrate
the location.
Fig. 4 • Top:Transverse section showing crack into
pulp. M id d !e :H ig h e r m agnification of transverse
section shown ab o ve. Bottom :Transverse and hori­
zontal section showing crack into pulp from o cclu ­
sal and proximal surfaces

Sensitivity to thermal changes in a

tooth that previously has been comfort­
able is the other common complaint. This
is differentiated easily from sensitive ce-
mentum by examination in the mouth.
In many teeth with occlusoproximal,
two-surface restorations, the crack can be
seen over the remaining intact marginal
ridge. Frequently, there will be occlusal
caries in the crack, or the crack may be
discovered when a cavity is prepared.
When there is no approximating tooth,
the crack may be seen along the entire
proximal surface or from the gingival
margin of a restoration apically (Fig. 3 ).
Some cracks can be seen by transillumina­
tion; others can be stained with iodine,
Mercurochrome or other dyes.
The difficult diagnosis occurs when no
crack can be seen. These teeth have
mesioocclusodistal restorations which ap­
pear serviceable. By wedging with an in­
strument along a margin, pain often can
be elicited. In others the restoration must
be removed before the crack is visible.
Some cracks are difficult to see in the pos­
terior of the mouth even though one feels
sure they must be present. Checks in the
enamel alone do not appear as wide or
deep as cracks extending deeper. A tooth
weakened by deep cavity preparation is
more suspect.
Electric pulp tests seldom are needed.
If there is an obvious crack but no symp­
toms, the pulp may be dead, and a pulp
test may help decide. A vital pulp re­
sponds to temperature changes and to
wedging the sides of a crack apart.
Full coverage of the apparently healthy
cracked vital tooth may be indicated to
prevent deeper cracking. T o try to deter­
mine the depth of the crack or to elimi­
nate it in a healthy vital tooth could be
dangerous. The pulp might be exposed
needlessly if the crack terminated near it.
 CA M ERO N . . . VO LUM E 68, MARCH 1744 • 95/409

As the crack deepens, the typical pain of in Table 2. Some patients had no symp­
pulpitis arises. The crack then can be toms; many had pain to more than one
followed to determine its extent and stimulus. A history o f discomfort before
whether extraction or endodontic therapy diagnosis ranging from one month to ten
and full coverage is the better method years was present in 29 of the 50 teeth.
o f treatment. In 7 teeth, temporary relief had been
achieved by adjusting the occlusion by
grinding.
RESU LTS
Tabulation of the types of old restora­
Fifty cracked teeth have been examined. tions was difficult. Some teeth had both
T h e histories have not all been complete, hard and soft gold inlays; some had gold
but the cracks were seen in every instance. inlays and silver amalgam fillings, and
If not seen in the mouth, they were found histories were incomplete for some teeth
after extraction and were examined with in which fillings were missing after ex­
the dissecting microscope (Fig. 4 ). The traction. O f the total number of restora­
teeth were then sectioned horizontally or tions, 35 per cent were soft gold, 13 per
transversely, or they were split and stained cent hard gold and 39 per cent amalgam ;
with safranine for depth o f plaque pene­ restorations were missing in 13 per cent.
tration (Fig. 5 ). Fractured teeth or those
with root canal fillings were not included.
Fifty-four per cent of the teeth were
from women, although one ordinarily
thinks o f men being more muscular and
biting harder. Patients were at least 35
years old. Some ages were known; others,
estimated. Forty per cent were 60 or over;
32 per cent were 50 or over, only 28 per
cent were under 50. It is well known that
teeth grow more brittle with age and
crack more easily, and these results sup­
port this. The locations of the teeth are
shown in Table 1.
T h e mandibular second molar was the
one most frequently cracked; generally,
the crack extended from the distal surface
over the occlusal surface, sometimes to or
including the mesial surface. In the max­
illary molars, the crack, if completed,
usually would have gone into the bifur­
cation, separating the two buccal roots
from the lingual one. Likewise an upper
bicuspid would tend to split between the
roots.
T w o thirds of these cracked teeth were
vital or acutely inflamed with a roentgen-
ographically normal apex. The other third
showed bone loss at the apex and were
obviously dead. O f the total, 27 were ex­
tracted; 21 were restored, and 2 are yet
Fig. 5 • A :Safran in e-stain ed plaque in crack ex­
to be treated. tend in g into pulp. B :C le a n fracture w here tooth
Th e tabulation o f symptoms is shown was split with chisel; there is no p laque to stain
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D IS C U S S IO N T ab le 2 • Symptoms of cracked teeth

Pain N o . of patients
I always had used soft 22 K gold for in­
lays but, after reading the work o f Ritchey Pressure 27
and others,6 I began using a harder gold.
Cold 16
M y results, however, show that teeth
Heat 14
filled with silver amalgam cracked even
Ache 9
more frequently than those filled with
Cellulitis 5
gold. Preliminary studies of photomicro­
graphs o f soft gold inlays show no distor­ Sw eet 1

tion below the surface in these cracked N one reported 6

teeth. I f the inlays had been distorted,

the force could have been transmitted
toward the walls o f the cavity, wedging
them apart. T h e inlays usually had been
seems to be a prolonged hammering. Al­
in place a number o f years, so that it is
most 60 per cent gave histories o f discom­
unlikely the cracks originated from mal-
fort for from one month to ten years. A
leting the inlays into place.
few could remember a sudden force, but
It seems doubtful that expansion o f
amalgam causes the cracking. The amal­ these usually had suffered complete frac­
gam fillings had also been in place many tures. Most occlusal surfaces had wear
years, and expansion was probably over facets, which are evidence o f interfer­
long before. I f the expansion was continu­ ences, interceptive contacts or bruxism.
ing or excessive, it apparently would Others had steep cusps and deep fossae
where wedging could explain the cracking.
cause the amalgam to flow out o f the
Patients vary in the amount o f muscle
cavity.8 T he cracking is most directly re­
lated to the depth of the cavity. The pressure used in biting. Many o f these
with cracked teeth delighted in exerting
cracking o f intact teeth without caries or
fillings can only be explained as a result maximum pressure on foods whether
of force. heeding it or not. They took pleasure in
biting hard. With over 200 lb. o f pressure
The force exerted to cause the crack
possible in multiple blows over a long
time, “ something has to give.”
The centrally located cracks seem to
follow the lines of the dentinal tubules
Table 1 • Locations of the cracked teeth
and lead toward the pulp, causing its ex­
Tooth N o. Per cent posure. The more peripheral cracks seem
to lead to cuspal fracture, with or with­
Mandibular
out pulpal exposure, depending on the
Second molars 17 34 amount of secondary dentin.
First molars 9 18 An interesting observation was that in­
Third molars 1 2 lays became uncemented in teeth that
Bicuspids 1 2 later proved to be cracked. Another was
Maxillary patient diagnosis. Seven patients had lost
First molars 12 24 another tooth by fracture. These patients
Second molars 2 4 said the pain of the cracked tooth was
First bicuspids & 12
the same as that of the previous tooth
before extraction. One patient was pleased
Second bicuspids 2 4
to have two cracked teeth discovered in
Total 50 100 a routine examination. H e already had
had three teeth extracted because of

cracking and was wearing a partial den­
ture replacing them. One cracked molar
either had been weakened by internal re­
sorption or had been stimulated to resorp­
tion by irritation from the crack. Relief
of symptoms by adjusting the occlusion
was only temporary; eventually the symp­
toms returned.
In six patients, there had been no pain
that they could remember. Five o f these
had cracks found on examination or dur­
ing cavity preparation. It is assumed they
had not progressed far enough to be pain­
ful, yet all had penetrated the dentin. The
remaining crack was found in an asymp­
tomatic tooth extracted because of radio-
lucency at the apex.
C O N C L U S IO N S
There is a cracked-tooth syndrome. An
awareness that these cracks occur is the
prime factor in diagnosis. The predomi­
105th Annual Session
o f the American Dental
Association and
52nd Annual Session
o f the Fédération
Dentaire Internationale
November 9-12, San Francisco
CAM ERO N . VO LUM E 68, MARCH 1964 • 97/411
nant symptom is discomfort to chewing
pressure. Unexplained sensitivity to ther­
mal changes is almost as important. Other
factors, such as staining, wedging and
tapping, assist in early diagnosis when full
coverage can prevent further cracking
and pulp exposure.
670 North Michigan Avenue
*Assîstant professor of diagnosis, Northwestern Uni­
versity Dental School, Chicago.
1. Gibbs, J . W . Cuspal fracture odontalgia. D. Digest
60:158 April 1954.
2. Mellion, G. L. Case report: a fractured molar
cusp. D. Survey 32:614 May 1956.
3. Thoma, Kurt H. Oral surgery, ed. 3. St. Louis,
C. V. Mosby Co., 1958.
4. Thoma, Kurt H. Oral pathology, ed. 5. St. Louis,
C. V. Mosby Co., I960.
5. Ritchey, Beryl; Mendenhall, Robert, and Orban,
Balint. Pulpitis resulting from incomplete tooth fracture.
Oral Surg., Oral Med. & Oral Path. 10:665 June 1957.
6. Sutton, P. R. N. Greenstick fracture of the tooth
crown. Brit. D. J . 112:362 May I, 1962.
7. Stuteville, O. H. Personal communication.
8. Skinner, E. W ., and Phillips, R. W . The science of
dental materials, ed. 5. Philadelphia, W . B. Saunders
Co., I960.