Cracked tooth

syndrome
Introduction

 Cracked tooth syndrome is a major diagnostic challenge

in clinical practice.
 Accurate diagnosis and appropriate treatment are
complicated due to lack of awareness of this condition
and its bizarre clinical features.
 Early diagnosis has been linked with successful
restorative management and good prognosis.
 Definition….

Cracked tooth syndrome may be defined as a fracture

plane of unknown depth, which originate from the crown,
passes through the tooth structure and extends subgingivally,
and may progress to connect with the pulp space and/or
periodontal ligament

Torabinejad M, Walton RE. Endodontics. Principles and Practice. 4th

ed.Philadelphia: Saunders; 2008. p. 110‑5.
Türp JC, Gobetti JP. The cracked tooth syndrome: An elusive diagnosis.J Am Dent
Assoc 1996;127:1502‑7
History…..

 Gibbs in 1954, was the first to describe the clinical symptoms

of incomplete fracture of posterior teeth involving the cusp and
termed it as “cuspal fracture odontalgia.”

 Cases of incomplete fracture with subsequent pulpitis were

reported by Ritchey et al. in 1957.
 Cameron in 1964 coined the term “CRACKED TOOTH
SYNDROME.”

He defined it as
an incomplete fracture of the vital
posterior tooth involving the dentin and possibly the
dental pulp.
 In the late 1970s, Maxwell and Braly advocated the use
of the term “incomplete tooth fracture”.

 Ellis defined, incomplete tooth fracture as a

“fracture plane of unknown depth and direction passing
through tooth structure, and may advance to connect with the
pulp and/or periodontal ligament.”

Brannstrom M. The hydrodynamic theory of dentinal pain: Sensation in preparations, caries, and
the dentinal crack syndrome. J Endod 1986;12:453‑7.

Kahler B, Moule A, Stenzel D. Bacterial contamination of cracks in symptomatic vital teeth. Aust
Endod J 2000;26:115‑8.

Maxwell EH, Braly BV. Incomplete tooth fracture. Prediction and prevention. CDA J 1977;5:51‑5.
 According to Leubke, fractures are either complete or
incomplete, although,
other terms such as split‑root syndrome,
hairline fracture, hairline tooth fracture, enamel
infraction, crown craze, craze lines, greenstick fracture
and tooth structure cracks are also known
Epidemiology

 The occurrence of cracked tooth syndrome is 34–74%

 Age: 30–50 years
 Sex prediliction : female predilection.
 Most commonly affected tooth
mandibular molar >maxillary premolar> maxillary
molar>mandibular premolar.
 Mandibular first molars are the first permanent teeth to
erupt into the dental arch, hence, they are more prone to
dental caries and subsequent restorative intervention.
Thus, they are more susceptible to fracture.

 The “wedging effect” upon lower first molar teeth

from the prominent mesio‑palatal cusp of maxillary first
molar teeth may also be contributory.

 Furthermore, mandibular molars have a deeper central

fossa than maxillary molars, and the oblique ridge of the
maxillary molars increases resistance to crack formation.
 A study by Kang et al.in 2016 found that the lower
second molars were the most commonly affected teeth
followed by lower first molars.

 The high incidence of cracks in the lower second

molars
may be related to their proximity to the
temporomandibular joint.

 Based on the lever effect, we may expect the

masticatory force on the tooth to be larger closer to
the TMJ.
 Upper premolars were more affected than lower
premolars, which may be associated with the deep cusp
-fossa relationships of upper premolars.
 Geursten et al. have reported that tooth fractures are
a potential major cause of tooth loss in the industrialised
world

 A study by Krell et al. has reported an incidence rate of

9.7% among 8,175 patients referred to a private
endodontic practice over a period of six years.
Etiology

 Cracked tooth syndrome has a multi‑factorial etiology.

 Geurtsen showed that

“excessive forces applied to a healthy tooth or physiologic
forces applied to a weakened tooth results in an
incomplete fracture of the enamel or dentine.”

Geurtsen W. The cracked‑tooth syndrome: Clinical features and case reports. Int
J Periodontics Restorative Dent 1992;12:395‑405.12.
Lynch and McConnell subdivided the etiology into 4 major
categories

MISCELLANE
RESTORATIVE OCCLUSAL DEVELOPMENTAL
OUS

Lynch CD, McConnell RJ. The cracked tooth syndrome. J Can Dent Assoc
2002;68:470‑5
 Restorative Inadequate design features
Stress concentration

 Occlusal Masticatory trauma

TFO
Functional forces
Parafunctional forces

 Developmental Incomplete fusion of areas of calcification

 Miscellaneous Thermal cycling

Foreign bodies
Dental Instruments
Restorative factors

Inadequate design features

 Over‑preparation of cavities (excessive tooth

removal)
 Deep cusp‑fossa relationship
 Insufficient cuspal protection in inlay/onlay design
 Stress Concentration

 Pin placement (friction lock or self‑threading dentin

pins)
 Non‑incremental application of composite resins (tensile
stress on cavity walls)
 Pressure exerted during the seating of tightly fitting
cast restorations
 Physical forces during placement of restoration, e.g.,
amalgam or soft gold inlays (historical
 Occlusal factors
 Masticatory trauma

Sudden and excessive cutting force on a piece of hard

object (bone)

 Trauma from occlusion

Eccentric contacts and interferences (especially
mandibular second molars)
 Functional forces
Large untreated carious lesions
Cyclic forces

 Parafunctional habits
Bruxism
Developmental factors

 Incomplete fusion of areas of calcifications

Occurrence of cracked tooth syndrome in unrestored tooth

or teeth with minor restorations
Miscellaneous factors

 Thermal cycling
Enamel cracks

 Foreign body
Lingual barbells

 Dental instruments
High speed rotary instruments associated crazing and
cracking
 Ratcliff et al., found that a tooth with an
intra‑coronal restoration is at a risk of fracture 29
times greater than that of an unrestored tooth.
Differences in the coefficients of thermal expansion
between the tooth tissue and restorative material may
also have the potential to induce fracture

Ratcliff S, Becker IM, Quinn L. Type and incidence of

cracks in posterior teeth. J Prosthet Dent
2001;86:168‑72
Classification

Several classifications have been proposed based on:

(a) The type or site of the crack
(b) the direction and degree of the crack
(c) the risk of symptoms
(d) pathological processes
 The American Association of Endodontists, in a
document titled “cracking the cracked tooth code”
identified five types of cracked teeth

 CRAZE LINES
 FRACTURED CUSPS
 CRACKED TOOTH
 SPLIT TOOTH
 VERTICAL ROOT FRACTURES

American Association of Endodontists. Cracking the cracked tooth code.

Endodontics:Colleagues for Excellence. Chicago: American Association of
Endodontists; 2008
Craze lines

 visible fractures and contained within the enamel.

 In posteriors, craze lines are usually seen to cross the

marginal ridges and/or extend along buccal and lingual
surfaces.

 Long vertical craze lines usually occur in anteriors

 Asymptomatic
Fractured cusps

 begin at the crown of the tooth, extend into dentin,

the fracture ends in the cervical part of the tooth.

 usually seen in heavily restored teeth, causing

unsupported cuspal enamel

 Mildly symptomatic, mainly on biting

on cold
cracked tooth

 indicative of a crack extending

from the occlusal surface of the tooth apically without
separation of the two fragments.

 generally located at the center of the tooth in a

mesiodistal direction and may involve one or both marginal
ridges
 Acute pain on biting, occasional sharp pain to cold
split tooth

 crack extending through both marginal ridges usually in

a mesiodistal direction splitting the tooth completely into
two individual fragments.

 The crack is generally located at the center of the tooth

and this entity occurs due to crack propagation

 Marked pain on chewing

Vertical root fractures

 commence in the root generally in a bucco‑lingual

direction.

 generally complete though may be incomplete and

involve only one surface

 may involve either the entire root or only a portion of

the root

 Vague pain mimicking periodontal disease.

 a b c

(a) Depicting visible fracture lines

within the enamel suggestive of
Craze lines;
(b) Fractured cusp terminating in
the cervical part of the tooth
(c) Cracked tooth extending from
the occlusal tooth surface without
separation of tooth fragments
(d) Separated tooth fragments
suggestive of a split tooth;
(e) Vertical root fracture

d e
Clinical Features

 varied clinical signs and symptoms, according to the

position and extent of the incomplete fracture.

 History of discomfort for several months and sharp pain

when biting or when consuming cold food/beverages
may be elicited
 “Rebound pain” ‑ pain on the release of pressure upon
intake of fibrous foods is a consistent feature.

 Pain may be elicited by the consumption of sugar

containing substances,and also by the act of tooth
grinding(bite tests) or during excursive mandibular
movements

 may not be able to locate the offending tooth

 Positive response to pulp vitality tests, exaggerated
response to cold thermal stimuli

 The absence of heat‑induced sensitivity may also be a

feature.
 Chronic pulpitis with no clinical symptoms may be seen
as a result of micro‑leakage of bacterial by‑products
and toxins.
 Cracks with pulpal involvement may result in pulpal and
periodontal symptoms

S. Banerji, S. B. Mehta and B. J. Millar BRITISH DENTAL JOURNAL

VOLUME 208 NO. 10 MAY 22 2010
Physiological mechanism

 Brännström and Aström proposed

the fractured sudden

portions of movement of
the tooth Activation of
fluid present
move myelinated acute pain
in the
independentl A‑type fibers
dentinal
y of each tubules
other

Pain on chewing
 concomitant
seepage of toxic lowering in the pain
release of . Hypersensitivity to
irritants through threshold of
neuropeptides cold
the crack unmyelinatedC‑typ
e fibers

Hypersensitivity to cold
 ‘symptoms are caused by the alternating stretching
and compressing of the odontoblast processes located
within the crack’

Dewberry JA. Vertical fractures of posterior teeth. In: Lieve FS,

editor. Endodontic Therapy. 5th ed. St. Louis: Mosby
Diagnosis

 Because of the variable and bizarre clinical signs and

symptoms,cracked tooth syndrome is a diagnostic
challenge for even the most experienced dental operators.

 The importance of an early diagnosis has been linked

with successful restorative management and prognosis
 Dental conditions that may present with similar features:

- acute periodontal diseases

- reversible pulpitis
- dentinal hypersensitivity
- galvanic pain associated with silver amalgam
restorations
- sensitivity following micro leakage from recently
placed composite resin restorations
- areas of hyper occlusion from dental restorations

-occlusal trauma from parafunctional habits

- orofacial pain arising from conditions such as
trigeminal neuralgia
- psychiatric disorders such as atypical facial pain
Dental history

 A thorough and detailed dental history may help in

eliciting certain distinct clues
 h/o:
- long‑term dental treatment
- multiple replacements of restorations
- occlusal adjustments
- parafunctional habits

 History of cold sensitivity and sharp pain on biting hard or

tough foods which ceases when the pressure is released is
an important indicator

 Symptoms may vary according to the depth and orientation

of the crack
Clinical examination
 application of a sharp straight probe to the margins of the
heavily restored tooth may evoke sharp pain

 Sometimes exploratory excavation may be needed to obtain

a visual diagnosis

 Clinical examination may also reveal the presence of wear

facets on the occlusal tooth surfaces, occurrence of
localized periodontal defects or the evocation of symptoms
by sweat or thermal stimuli

 The use of rubber dam enhances the probability of

visualizing these cracks
Periodontal probing

 Cracked tooth and a split tooth may be differentiated

by periodontal probing.

 The localized periodontal defect is the result of a

fracture line extending below the gingiva.

 Isolated deep probing reveal the presence of a split

tooth, indicating a poor prognosis
Dye test

 Special stains such as methylene blue or gentian violet

are frequently used to highlight the cracks.
 However, a long time (at least 2–5 days) is needed to be
effective and may require placement of a provisional
restoration.
 This may weaken the tooth integrity and further spread
the crack.
 Another disadvantage is difficult esthetic restoration.
Bite tests

 Pain on biting that ceases after the pressure has been

withdrawn is a classical sign.

 Symptoms may be elicited when pressure is applied to

an individual cusp.This forms the basis of so‑called
“bite tests.”
 patient is asked to bite on
various items such as a toothpick,
cotton roll, rubber abrasive
wheels such as burlew wheel,
orange wooden stick or the
commercially available Tooth
Slooth (Professional ResultsInc.,
Laguna Niguel, CA, USA).
Vitality tests

 Vitality tests for individual teeth are usually positive.

 Sometimes the affected teeth may show signs of

hypersensitivity to cold thermal stimuli due to the
presence of pulpal inflammation; a feature that may
help to confirm a diagnosis of cracked tooth syndrome.

 may be seldom tender on apical percussion.

Radiographs

 Diagnosis of cracked tooth syndrome by radiographs is

usually questionable, as fractures propagate in a
mesiodistal direction;parallel to the plane of the film.

 Fractures occurring in a bucco‑lingual direction is more

readily noticed on radiographs.

 Radiographs may be helpful in assessing the status of

the pulp and periodontium, and for excluding other
dental pathology
 Tooth cracks may not show up on radiographs since X-ray
photons passing through a radiolucent fracture plane also pass
through extensive amounts of radiopaque healthy tooth
structure.
A tooth may be cracked if it shows, on a radiograph, a large peri
-apical radiolucency that is contiguous with a furcation, or an
entire root surrounded by a radiolucency.
Transillumination

 Transillumination is an important aid in diagnosing the

cracks, whether it is an incomplete crack (as in cracked
tooth syndrome) or a complete vertical root fracture
 In transillumination, the tooth is cleaned and a
fiber‑optic or other light source is applied directly on
the tooth.
 A crack will block the transmission of light, and
structurally sound teeth (including those with craze
lines) will transmit the light throughout the crown
Microscopic detection

 using microscopes (×6–8 magnification or greater) and

shadow‑free co‑axial illumination that is coincident with
the dentist’s viewing axes, when observing cracked
teeth,is recommended instead of unaided vision or entry
level ×2.5 magnification,or shadow-forming overhead
lighting.
 Microscopes facilitate observation of microscopic
crack lines that may show minimal color contrasts
against a desiccated tooth surface , without
needing trans-illumination or dyes to observe crack
lines.

 Microscopically precise tactile sensation permits

verification of a crack by associating the tactile sensation
of an explorer tip falling into a cleft with the microscopic
point on a crack line where the tip is located
 A sensitive premolar shows a cleft and a
microscopically thin crack line, with a
minimal color contrast with surrounding
tooth structure

A periodontal probe in the premolar

separates the cracked piece
 . Microscopes permit detecting microscopic amounts of debris
in the cleft, or microscopic differences, in the respective
directions of movement,of separate tooth structures shifting
independently of one another around a cleft
 Stripping a microscopically thin layer from a surface with a
deep craze line may reveal uncracked underlying tooth
structure, indicating that the crack is superficial.
 Microscopes permit accurate visual estimation of the
steepness of cuspal inclines, and allow precise observation of
where a pointy lingual plunger cusp occludes into an opposing
tooth, and observation if a microscopic crack line is
developing around this contact area
 . Microscopic amounts of chalky white or beige
discoloration underneath a cusp can be indicative of
caries under the cusp, which sometimes can be
overlying a fracture plane.
 Microscopes facilitate observing microscopic gaps or
elevations of restoration margins, which may indicate
cracks.
 Microscopes improve the ability to understand the
dimensions of foreshortened surfaces.

 This facilitates observing a marginal ridge crack from an

occlusal viewing vantage point, to assess how closely to
the gingiva the crack has propagated
 Using microscopes and co-axial illumination, a dentist
may drill an exploratory column through a crack
line, to observe the depth at which the crack line
disappears, or to assess if the crack line extends into
the pulp chamber roof.
 Sometimes, such exploratory drilling may be necessary to
allow a dentist to discover that an asymptomatic tooth has a
fracture plane that extends into the pulp chamber.
 If a fracture plane extends into the pulp chamber floor,
this could hinder endodontic sealing of the chamber,
although endodontic treatment may last indefinitely.

 If the fracture plane clefts the pulp chamber floor, the

fracture may be catastrophic.

Cracked tooth diagnosis and treatment: An alternative

paradigm ,John S. Mamoun,2015
Indirect diagnostic measures

 the use of copper rings, acrylic provisional crowns, and

stainless steel orthodontic bands, may also be used
TRIAL SPLINTS

 Another indirect diagnostic method

 Composite resin is placed over the tooth without

etching and bonding.

 The patient feels marked improvement in discomfort on

biting, as the material acts as a splint to detect cracked
tooth syndrome
An example of a trial localised supportive
composite splint
Management

 The treatment of a cracked tooth depends on the

site,direction, size or the degree of the crack.
 Minor cracks : restored with a filling or a crown.
 Deep cracks with pulp involvement :RCT & crown.

In the worst case scenario, a cracked tooth cannot be repaired.

 crack extends into the root of the tooth beneath the bone:

require the removal of the tooth and replace with a

dental implant or a dental bridge
 John S. Mamoun in his article Cracked tooth diagnosis
and treatment: An alternative paradigm,2015 has
proposed newer treatment options for cracked tooth

1)Enamel craze line

TREATMENT
 • I n general, no treatment is req uired
2)Cuspal fracture, with fracture plane
completely supra-gingival, or no more than 1-
3mm sub-gingivally

 • Polish tooth and watch, without making a direct restoration

 • Place a direct restoration
 • Place a crown if the remaining tooth structure does provide
enough retention to retain a direct restoration
 • If the cuspal fracture plane is bounded by a direct
restoration, the crack may have resulted from the stress on the
tooth structure caused by the act of retaining the restoration.
Consider placing a crown, particularly if, after removing the old
restoration, the remaining tooth structure shows cracks
 • Assess the need for endodontic treatment if remaining tooth
structure is cracked
3)Cuspal fracture, with fracture plane more
than 3mm sub-gingivally

Treatment

 • Consider extraction
 • Restoration may be possible with crown lengthening
surgery or if a very small
 segment of the tooth cross-sectional perimeter is deeply
sub-gingival
 • Endodontic treatment may be needed if fracture
plane intersects pulp chamber
4)Furcation fracture, with fracture plane not
into pulp chamber roof or floor
TREATMENT
 • If the patient is relatively young and tooth is in
occlusion, consider a crown
 • If the patient is relatively old, and fracture is
incipient, consider watching
 • If the tooth is not in occlusion or is opposed by a full
denture, consider watching
 • A posterior tooth with a class II restoration occupying
one marginal ridge and a crack in the unrestored
marginal ridge, may require a crown to prevent further
crack propagation
5)Furcation fracture, with fracture plane
into pulp chamber roof or side

TREATMENT
 • Endodontic treatment, then place a crown
6)Furcation fracture, with fracture plane
into pulp chamber floor
TREATMENT
 • Often a catastrophic fracture requiring extraction,
especially if there is clefting in pulp chamber floor
 • Consider endodontic treatment and then place a
crown, if onlya hairline fracture is visible in pulp
chamber floor
 • Hemi-section may be possible with isolated root
fractures in molars. However,extracting the tooth and
placing an implant may be a more predictable
treatment
7)Root fracture
TREATMENT
 • Often a catastrophic fracture requiring extraction
 • A root fracture where the root has a preexisting post
is not likely to become more stable by re-making the
post, core, and crown
8)Gingival interface fracture

TREATMENT
 If the gingival interface is completely fractured, the
fracture is usually catastrophic, although occasionally
crown lengthening surgery followed by a crown can
salvage tooth
 If the fracture is incipient, with <1/3 of the gingival
interface area fractured, consider endodontic
treatment, post, and crown
 (a) Fracture line running
mesiodistally in 46,
(b) Preoperative radiograph
of 46

(a) Post-endodontic picture

showing composite core build-
up, crown preparation
(b) Full metal ceramic crown in
46

(a) Postoperative radiograph of

46 at 6 months,
(b) Postoperative at 6 months
follow-up and clinically
healthy gingiva

Kadandale Sadasiva et al j pharm bioallied science 2015 aug 7

(a) Preoperative radiograph of 47,
(b) Crack line from central
fissure, crosses distal marginal
ridge covering the distal
surface of 47,
(c) Restoration with composite in
place
a) Fractured 46 seen involving the chamber,
(b) Preoperative radiograph, 46 showing carious lesion, and fractured amalgam
restoration,
c) Extracted tooth showing vertical fracture
Prognosis

 According to Clark and Caughman, the prognosis of cracked

teeth can be excellent, good, poor, and hopeless.

• Excellent:
(a) Cuspal fractures within the dentin that
angle from the faciopulpal or linguopulpal line angle of a
cusp to the cemento‑enamel junction or slightly below.
(b) Horizontal fracture of a cusp not involving the pulp

• Good: A coronal vertical fracture that runs mesiodistally

into the dentin but not into the pulp
 • Poor: A coronal vertical fracture that runs mesiodistally
into the dentin and pulp, but is limited to the crown

• Hopeless: A coronal vertical fracture that runs

mesiodistally through the pulp and extends into the root

Clark LL, Caughman WF. Restorative treatment for the cracked tooth.
Oper Dent 1984;9:136‑42.
Prevention

 Awareness of the existence and etiology of CTS is an

essential component of its prevention.
 Cavities should be prepared as conservatively as
possible.
 Rounded internal line angles should be preferred to
sharp line angles to avoid stress concentration.
 Adequate cuspal protection should be incorporated in
the design of cast restorations.
 Cast restorations should fit passively to prevent
generation of excess hydraulic pressure during placement.

 Pins should be placed in sound dentine, at an

appropriate distance from the enamel to avoid
unnecessary stress concentration.

 The prophylactic removal of eccentric contacts has

been suggested for patients with a history of CTS
Conclusion

Cracked tooth syndrome is a common and

well‑documented entity in the clinical practice.

Patients usually present with a wide variety of

signs and symptoms, thus making the diagnosis difficult
and complicated.

Detailed history and thorough clinical examination

may help in establishing a correct diagnosis and hence
that an appropriate treatment plan can be instituted.