Presented by Syed.khaja Ali uddin M.Sc.

D (Endo)

€ €

What is cracked tooth syndrome? Cracked tooth syndrome 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 (abbreviated CTS) is a medical condition in which a crack extends through the dentin, and occasionally through the pulp of a posterior tooth .

€

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

€

ENDODONTIC PRACTICE³LOUIS I GROSSMAN 11TH EDITION, pg no 60

€ 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 endodontics² mahmoud torabinejad, 4th edition. Pg no 113 Pathways of pulp² cohen 9th edition, pg no 24.

€

€ CRACKED TOOTH

IS ALSO CALLED AS ´INCOMPLETE (GREENSTICK)FRACTURESµ

€

Pg no 67,text book of endodontics ² anil kohli

€ 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

disease can 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 endodontics² mahmoud torabinejad, 4th 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 ² anil kohli

€ The

teeth usually involved are molars maxillary premolar

€ Mandibular

maxillary 1st molar

Pg no 67,text book of endodontics ² anil kohli

€ 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 endodontics² mahmoud torabinejad, 4th edition. Pg no 116

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.
€ It
€

Principles and practice of endodontics² mahmoud torabinejad, 4th edition. Pg no 116

€ Crack € They

cross one or both marginal ridges.

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 endodontics² 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 stickµ because it incomplete.

€

Principles and practice of endodontics² mahmoud torabinejad, 4th edition. Pg no 114

€ Pulp

and periapical tests also have variable results. the pulp is usually responsive(vital) but may be non responsive (necrosis). tests are also vary, but usually pain is not elicited with percussion or palpation if the pulp is vital.
‡ Principles and practice of endodontics² mahmoud torabinejad, 4th

€ Periapical

edition. Pg no 114

€ Directional

percussion is also advocated. € Percussion that separate the crack cause pain.

€

Principles and practice of endodontics² mahmoud torabinejad, 4th edition. Pg no 114

€ 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 endodontics² mahmoud torabinejad, 4th edition. Pg no 115

€ Occlusal

and proximal restorations are first removed. transillumination,which often shows a characteristic abrupt blockage of transmitted light, is performed. transillumination the portion of the tooth where the light originates illuminates to the fracture. fracture contains a thin air space,which doesnot readily transmit light.

€ Then

€ With

€A

€ Therefore,the

crack (or fracture) blocks or reflects the light,causing the other portion to appear dark.

€

Principles and practice of endodontics² mahmoud torabinejad, 4th edition. Pg no 115

€ 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.

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.
€ Viewing

€ 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. 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.

€ Removal

€ 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 ²coloured 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

€

€ Selective

biting on objects is helpful, particularly when pain is reported on mastication. 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,

€ It

€ 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 PRACTICE³LOUIS I GROSSMAN 11TH EDITION, pg no 60

€ Because

of the mesio-distal direction of the fracture, it is not visible radiographically. 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 endodontics² mahmoud torabinejad, 4th edition. Pg no 115

€ Newer

€

€The

Cracked Tooth Syndrome

€ € €

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

€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. term was ¿rst 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 fracturesµ of the crown.

€ The

€A

more recent attempt to de¿ne 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 ligamentµ.

€ 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 ¿rst 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. ¿rst occurs when the crack is centrally located, and following the dentinal tubules may extend to the pulp.

€ The

€ The

second is where the crack is more peripherally directed and may result in cuspal fracture.

€ Separation

in dentine results in the movement of Àuid 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.

€ Successful

diagnosis of CTS requires awareness of its existence and of the appropriate diagnostic tests. history elicited from the patient can give certain distinct clues. on biting that ceases after the pressure has been withdrawn is a classical sign.

€ The

€ Pain

€ 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 ¿bres in the pulp chamber). testing usually gives a positive response, and the tooth is not normally tender to percussion in an axial direction

€ Vitality

: 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 testsµ 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). results of these ´bite testsµ are conclusive in forming a diagnosis.

€ The

Classification Factors

Examples

Restorative procedures

Inadequate design features

Over-preparation of cavities. Insufficient cuspal protection in inlay/onlay design. Deep cusp²fossa relationship 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

Stress concentration

Classification Occlusal

Factors Masticatory accident

Examples Sudden and excessive biting force on a piece of bone Eccentric contacts and interferences (especially mandibular second molars) Large untreated carious lesions Cyclic forces Bruxism

Damaging horizontal forces

Functional forces

Parafunction

Classification Developmental

Factors Incomplete fusion of areas of calcification Thermal cycling Dental instruments

Examples Occurrence of cracked tooth syndrome in unrestored teeth Enamel cracks Cracking and crazing associated with highspeed handpieces

Miscellaneous

€ INTRODUCTION € Gibbs

in 1954 was the first to describe cracked teeth using the term ¶Cuspal fracture odontalgia· . 1957, Ritchey et al reported cases of incomplete fracture with subsequent pulpitis .

€ In

€ The

term ¶cracked tooth syndrome· was coined by Cameron in 1964. Cameron·s 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, split-root syndrome, enamel infraction, hairline tooth fracture, crown craze, craze lines and tooth structure cracks, Luebke considered fractures as either complete or incomplete

€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. pain was sharp, intermittent in nature which increased on chewing hard substances. The medical history of the patient was noncontributory. history revealed root canal therapy of the right mandibular first molar 4 years ago.

€ The

€ Dental

€ Clinical

examination revealed fractured tooth with the fracture line running buccolingually. 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

€ The

€

€

€ 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.

€ 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. good history will provide vital assistance in the search for a diagnosis.

€A

€ 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.

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