Definition:

- Cracked tooth syndrome is 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 American Association of Endodontists defines the term cracked tooth as an incomplete
fracture initiated from the crown and extending subgingivally, usually directed mesiodistally.
- Cracked teeth are also described as greenstick fractures or tooth infractions.

Epidemiology:
- Cracked teeth are more prevalent at middle-aged and older patients
- Molars are more often affected than premolars probably due to the proximity to the
temporomandibular joint. Thus, eating course food, chewing on hard objects, and unilateral
mastication were identified.
- Mandibular molars crack more frequently than maxillary molars which show mor resistant to
cracks due the stabilizing effect of occlusal oblique ridge.
- Due to higher masticatory forces in men the prevalence of cracked teeth might be higher in
males than females.
- Cracks occur in intact and restored teeth. If cracks occur in restored teeth, those with nonbonded
restorations, such as gold and amalgam are more often affected than teeth with bonded
restorations (composite) or crowns.

Classification:
1. Craze line
- Craze lines extend over marginal ridges and buccal and lingual surfaces in posterior teeth and
appear as long vertical lines in anterior teeth but are confined to enamel
• Only enamel
• Pulp vital
• No symptoms
• Variable direction
• Excellent prognosis
2. Fractured cusp
- Fractured cusps are defined as complete or incomplete fracture involving at least two aspects of
the cusp and extending to the cervical third of the crown
• Crown
• Usually vital pulp
• Mild pain usually to biting and cold
• Good Prognosis

3. Cracked tooth
• Crown and / or Root
• Variable pulp status
• Acute pain on biting
• Sharp pain on cold
• Prognosis dependent on depth and extent of the crack

4. Split tooth
- Split tooth is defined as complete fracture initiated from the crown and extending the middle or
apical part of the root.
• Crown and root
• Usually root filled
• Marked pain on chewing
• Poor prognosis unless crack terminates just subgingivally
5. Vertical root fracture
• Root
• Mainly root filled
• Vague pain mimics periodontal disease
• Poor prognosis (may root resection)

Etiology:
- Intact, non-restored teeth often exhibit tooth cracks at the surface, developing in enamel or at
the DEJ, which might progress into dentin, but are less likely to cause tooth fracture.
- Tooth fracture is more likely to occur from dentin cracks, which might be a result of restorative
procedures (e.g., removal of tooth structure) or fatigue caused by the restoration.
- Natural predisposing factors responsible for the development and progression of cracks in
intact teeth include morphological and physical factors, such as:
• sudden biting on hard substances
• eccentric contacts and interferences
• wear, bruxism, malocclusion
- If the fracture resistance of teeth is reduced due to the presence of carious lesions, requiring
extensive preparation and resulting in large and/or deep cavities
- Occlusal load stress during mastication and repeated thermal expansion of non-bonded
restorative material might cause an increased cuspal flexure inducing stress and producing
microcracks.
- Inadequate cavity design features also comprise insufficient cuspal protection in inlay/onlay
design.
- Stress concentration due to pin placement
- Non-incremental placement of composite restorations might predispose crack formation due to
high polymerization shrinkage stresses at the interface specially if the remaining tooth structure is
weak.
- Trauma, Patients practicing contact sport and Endo treated tooth

Diagnosis:
The main clinical signs and symptoms of cracked teeth are:
• Pain on biting/chewing
• Sometimes on the release of pressure (rebound pain)
• Sensitivity to cold thermal stimuli
- Symptoms might be present for periods ranging from weeks to month, and patients might have
difficulties in identifying the affected tooth
- Periodontal probing is necessary to disclose the depth of the crack. Cracked teeth with
periodontal probing depths exceeding 4 mm are more likely to show pulp necrosis than cracked
teeth with a periodontal probing depth of 3 mm or less.
- The pulpal and periapical diagnosis depends on the extent and orientation of the crack. In the
absence of pulpal inflammation, vitality testing usually gives a positive response
- Symptoms can be provoked by loading of individual cusps (so-called bite test) by specific
instruments (Tooth Slooth or FracFinder) for detecting cracked teeth. (FracFinder) presents a flat
surface to rest on the opposing tooth of that being tested. The opposite surface presents a concavity
that can be adapted to the suspected cusp, concentrating the load on the individual cusp so help in
identifying the cracked cusp. Biting tests can be also performed with wood sticks or cotton rolls,
but they can’t identify the cracked cusp.
- Visual detection of cracks is improved by using magnifying loupes/microscopes, dyes, fiber-
optic transillumination, or light-induced fluorescence.

Fiber-optic transillumination for detection of cracks

Observation of tooth cracks by light-induced fluorescence using intraoral QLF camera

- In case of restored teeth, especially in case of amalgam fillings or gold restorations, removal of
restorations is necessary to detect fracture lines. Then, wedging forces can be applied to
determine if tooth segments are separable or not.
 fracture line observed after removal of the restoration at the linguogingival line angle

- Radiographic examination rarely improves the detection of cracks, as fractures in mesiodistal

direction are usually not visible, but is essential to determine the periodontal and periapical status.

Management of Cracked Teeth:

The best treatment is Prevention:

• Recognition of predisposing factors and control them

• Recognition of signs and symptoms

• Provision of adequate restorations that protect the tooth from fracture.

• Early diagnosis to limit the propagation of the crack

- Treatment of longitudinal fractures depends on the extent and depth.

- Root canal treatment might be necessary in case of pulpal inflammation/ necrosis.
- If the crack extends to the root surface and leads to extensive attachment loss, extraction or – in
case of multi-root teeth – hemisection must be considered.
- Restorative treatment of incomplete coronal fractures not involving pulp or periodontium aims
to immobilize and bind the fractured segments.

- Historically, orthodontic bands, copper rings, or temporary crowns were suggested for
immediate treatment, but such restorations are time-consuming, invasive, and/or costly.
- In many cases, initial treatment can be performed by placing intracoronal composite
restorations
- Another restorative option includes indirect restorations (inlay, onlay and crowns)

GOOD LUCK