CRACKED TOOTH

SYNDROME

Presented by
Syed.khaja Ali uddin
M.Sc.D (Endo)
 INTRODUCTION
 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
 What is 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
syndrome”

 ENDODONTIC PRACTICE—LOUIS I GROSSMAN 11TH EDITION, pg no 60

 What is cracked tooth syndrome?
 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 endodontics– mahmoud torabinejad, 4 th edition. Pg no

113

 Pathways of pulp– cohen 9th edition, pg no 24.

 CRACKED TOOTH IS ALSO CALLED AS
“INCOMPLETE (GREENSTICK)FRACTURES”

 Pg no 67,text book of endodontics – anil kohli

ETIOLOGY
 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 endodontics– mahmoud torabinejad, 4 th 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 – anil kohli

 Incidence
 The teeth usually involved are

 Mandibular molars maxillary premolar

maxillary 1st molar

Pg no 67,text book of endodontics – anil kohli

 Signs and symptoms
 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 endodontics– mahmoud torabinejad, 4th edition. Pg
no 116
 It 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.
 Principles and practice of endodontics– mahmoud torabinejad, 4th edition. Pg
no 116
 Crack cross one or both marginal ridges.

 They 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 endodontics– 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 stick”
because it incomplete.

 Principles and practice of endodontics– mahmoud torabinejad, 4 th edition. Pg no 114

 Objective test
 Pulp and periapical tests also have variable
results. the pulp is usually responsive(vital) but
may be non responsive (necrosis).

 Periapical tests are also vary, but usually pain is

not elicited with percussion or palpation if the
pulp is vital.

• Principles and practice of endodontics– mahmoud torabinejad, 4th edition. Pg no

114
 Directional percussion is also advocated.
 Percussion that separate the crack cause pain.

 Principles and practice of endodontics– mahmoud torabinejad, 4th edition. Pg

no 114
 Other important objective tests

 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 endodontics– mahmoud torabinejad, 4 th edition. Pg no

115
 Occlusal and proximal restorations are first
removed.

 Then transillumination,which often shows a

characteristic abrupt blockage of transmitted light,
is performed.

 With transillumination the portion of the tooth

where the light originates illuminates to the
fracture.

 A fracture contains a thin air space,which doesnot

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

 Principles and practice of endodontics– mahmoud torabinejad, 4 th edition. Pg no

115
 Staining
 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.
 Viewing 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.
 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.

 Removal 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.
 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 –coloured 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
 Biting test
 Selective biting on objects is helpful, particularly
when pain is reported on mastication.

 It 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,
 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 PRACTICE—LOUIS I GROSSMAN 11TH EDITION, pg no 60

 Radiographic findings
 Because of the mesio-distal direction of the
fracture, it is not visible radiographically.

 Newer 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 endodontics– mahmoud torabinejad, 4th edition. Pg no
115
Treatment
 The Cracked Tooth Syndrome

 • Christopher D. Lynch, BDS, MFDRCSI •

 • Robert J. McConnell, BDS, PhD, FFDRCSI •
 J Can Dent Assoc 2002; 68(8):470-5
 Introduction
 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.

 The term was first 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 fractures” of the crown.
 A more recent attempt to define 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 ligament”.
 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 first 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.

 The first occurs when the crack is centrally

located, and following the dentinal tubules
may extend to the pulp.

 The second is where the crack is more

peripherally directed and may result in cuspal
fracture.
 Separation in dentine results in the movement
of fluid 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.
 Symptoms and Diagnosis
 Successful diagnosis of CTS requires
awareness of its existence and of the
appropriate diagnostic tests.

 The history elicited from the patient can give

certain distinct clues.

 Pain on biting that ceases after the pressure has

been withdrawn is a classical sign.
 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
fibres in the pulp chamber).

 Vitality testing usually gives a positive

response, and the tooth is not normally tender
to percussion in an axial direction
: 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

tests” 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).

 The results of these “bite tests” are conclusive in

forming a diagnosis.
 The etiology of cracked tooth syndrome
Classification Factors Examples

Restorative Inadequate design Over-preparation of cavities.

procedures features Insufficient cuspal protection in
inlay/onlay design.
Deep cusp–fossa relationship

Stress concentration 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
Classification Factors Examples

Occlusal Masticatory accident Sudden and excessive

biting force on a piece of
bone

Damaging horizontal forces Eccentric contacts and

interferences (especially
mandibular second molars)

Functional forces Large untreated carious

lesions
Cyclic forces

Parafunction Bruxism
Classification Factors Examples

Developmental Incomplete fusion of areas Occurrence of cracked

of calcification tooth syndrome in
unrestored teeth

Miscellaneous Thermal cycling Enamel cracks

Dental instruments Cracking and crazing

associated with high-speed
handpieces
 Case report
 INTRODUCTION

 Gibbs in 1954 was the first to describe cracked

teeth using the term ‘Cuspal fracture
odontalgia’ .

 In 1957, Ritchey et al reported cases of

incomplete fracture with subsequent pulpitis .
 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
 Case report
 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.

 The pain was sharp, intermittent in nature which

increased on chewing hard substances. The
medical history of the patient was
noncontributory.

 Dental history revealed root canal therapy of the

right mandibular first molar 4 years ago.
 Clinical examination revealed fractured tooth
with the fracture line running buccolingually.

 The 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
 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
Tooth finally restored with
composite and prepared for a
a metal crown.
metal crown.
 Tooth was bonded and
Cracked right mandibular
prepared to be restored with
first molar with a metal band
a metal ceramic crown.
placed on it to prevent crack
propagation.
The tooth finally restored
with a metal ceramic crown.
 Conclusion

 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.

 A good history will provide vital assistance in

the search for a diagnosis.
 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.
Thank you all