ENDODONTOLOGY

Management of cracked teeth - a case report

Neelam Mittal *
Vishal Sharma **
Anshu Minocha ***

ABSTRACT
Cracked tooth syndrome is a very common and well documented condition. Many morphologic, physical
and iatrogenic factors predispose posterior teeth to an incomplete fracture. Diagnosis is a difficult task because
the patient often presents with bizarre symptoms. Epidemiologic data revealed that splits or fractures are the third
most common cause of tooth loss, indicating the high clinical significance of this syndrome. These case reports
describe the treatment of patients presenting with variable complaints of pain associated with biting and sensitivity
of teeth. Clinical examination revealed teeth with crack lines and associated pulpal inflammation. The teeth were
splinted, root canal treated and restored. The patient’s responded well. The prognosis of teeth with cracks depends
on the location and extent of the crack. Early recognition and treatment is the key to proper management.
Key words: Cracked tooth, bonding, splinting.

INTRODUCTION Luebke considered fractures as either complete or

Gibbs in 1954 was the first to describe cracked
teeth using the term ‘Cuspal fracture odontalgia’ (1).
In 1957, Ritchey et al reported cases of incomplete
(2)
fracture with subsequent pulpitis
‘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 (3).
In the late 1970s, Maxwell and Braly advocated
use of the term incomplete tooth fracture (4). 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,
incomplete (5).
The most common cause of an incomplete
fracture is masticatory or accidental trauma.
. The term
Unintentional biting with physiologic masticatory
force on a small and very hard object may suddenly
generate an excessive load that may cause the tooth
to split. A number of co-factors like extensive tooth
preparation, unrestored deep carious lesions, teeth
endodontic cells treated teeth, deep grooves or
pronounced radicular grooves or bifurcation also
make teeth susceptible to fracture. Iatrogenic factors
like rotating instruments during cavity preparation,
overzealous condensation of amalgam, excessive
lateral condensation of Gutta percha and placement
of friction lock or self threading pins may also
contribute to tooth fractures.

* 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.

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ENDODONTOLOGY
Incomplete tooth cracks generally run in a
mesiodistal direction (81.1%). Rarely horizontal,
vertical or orovestibular cracks are seen. These
cracks are either limited to the crown or may involve
the root. It is most commonly observed in teeth with
no restorations (35%) and with class I restorations
(39%) and with class II restorations (26%).The most
prevalent age was over 40 years of age and the
prevalence was similar in men (53.9%) and women
(46.1%). Mandibular molars (67%) were more prone
to incomplete fractures than maxillary molars
Diagnosis is a difficult task, sharp pain on
chewing hard substances is important diagnostic
evidence. It is speculated that this short and sharp
pain is generated by an alternating stretching and
compressing of odontoblastic processes located in
the crack. Visual detection may be difficult as
Caufield’s analysis of crack lines under a scanning
electron microscope demonstrated that the width
(8)
of the fracture plane can be less than . Magnifying
glasses, transillumination, staining with methylene
(8, 12)
blue are useful in visualizing cracks
days ultrasound imaging system is being used for
crack detection (9).
The use of radiographs to detect cracks is
controversial. Radiographs may reveal the fracture
line if it is in direct alignment with the central rays
but since many fractures run mesio-distally, or in
some intermediate plane, alignment is not possible.
However, they are required to assess the periapical
(6, 7, 10, and 11)
and periodontal status of teeth .
The primary goal is to splint and stabilize a
cracked tooth to prevent further extension or
complete fracture of the tooth.
MANAGEMENT OF CRACKED TEETH - CASE REPORTS
Case Report 1
A 35 years old female patient came to the
faculty of Dental Sciences, Banaras Hindu
University, Varanasi, India with the chief compliant
of pain and sensitivity in right maxillary 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 maxillary first molar 1 year ago.
(6, 7)
.
Clinical examination revealed fractured right
maxillary first molar with the fracture line running
buccolingually in the crown region. The tooth was
not restored with a crown restoration after therapy
and occlusal loading may be the cause of fracture.
Radiographic examination revealed adequate root
canal filling with no signs of periodontal
involvement. A tooth slooth was used to confirm
the diagnosis.
Orthodontic steel band was fabricated and
cemented to the tooth and the tooth was
. Now a
disoccluded. After a month, the crack was reinforced
with bonded composite restorative material and was
finally restored with a full coverage metal crown
restoration.
Case Report 2
A 42 year old male reported at the Faculty of
Dental Sciences, Banaras Hindu University,
Varanasi, India, with the chief compliant of pain
and swelling in the left mandibular posterior region
for the past 6 months.
Clinical examination showed redness and
swelling associated with the left mandibular first
molar region and the overlying area was tender to
palpation. The tooth was tender to percussion. On
40
ENDODONTOLOGY
closer inspection, a superficial crack was observed
running in a mesio distal direction. A periapical
radiograph showed carious exposed left mandibular
first molar with periapical changes associated with
the roots of the tooth.
The tooth was disoccluded and an orthodontic
band was cemented to the tooth for stabilization.
Root canal therapy was performed and after 3
months, the tooth was bonded with composite
restoration and restored with a full coverage crown.
Case Report 3
A 40 year old male reported at the Faculty of
Dental Sciences, Banaras Hindu University,
Varanasi, India, with the chief compliant of pain
and in the right maxillary posterior region for the
past 2 months.
Clinical examination showed redness
associated with right maxillary first molar and the
overlying area was tender to palpation. The tooth
was tender to percussion. On closer inspection, a
superficial crack was observed running in a mesio
distal direction. A periapical radiograph showed
carious exposed left mandibular first molar with
periapical changes associated with the roots of the
tooth.
The tooth was disoccluded and an orthodontic
band was cemented to the tooth for stabilization.
Root canal therapy was performed and after 1
month, the tooth was bonded with composite
restoration and restored with a full coverage crown.
Case Report 4
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
41
Neelam Mittal, Vishal Sharma, Anshu Minocha
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.
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.
DISCUSSION
Tiny cracks are common and usually do not
cause problems. In such cases regular checkups are
important to treat problems in an early stage.
Various treatment modalities are available and
the choice depends on the location, direction and
extent of the crack. Cracks may be superficial,
affecting the cusp of a tooth or deep involving the
root of the tooth. Some affect only the enamel; others
may involve the dentin or the pulp. Before the
treatment, reduction or elimination of occlusal
contacts to avoid an overload of a split tooth is done.
The primary splinting is a must to prevent further
extension of the crack. Erhmann and Tyas (13)
suggested the use of orthodontic steel bands for this
purpose. A high success rate has been reported
when full-coverage acrylic provisional crowns were
ENDODONTOLOGY
used to stabilize the compromised tooth. Diagnosis
can be verified directly after splinting since the
diagnostic bite test will no longer provoke the typical
relief pain. This has the advantage of allowing time
to see the reversibility of the symptoms and after 2-
4 wks the tooth should be examined and if
symptoms of irreversible pulpitis are evident,
endodontic treatment should be performed. About
20% of teeth with cracked tooth syndrome need
(22)
root canal treatment . expose the margin; however, an unfavourable
Permanent stabilization can be achieved with
an adhesive intracoronal restoration e.g., bonded
amalgam, adhesive composite restorations, fibre
reinforced composites or a cast extra coronal
restoration e.g., Gold and porcelain inlays, onlay
or three-quarter crown with adequate cuspal
(14-17)
protection, and full-coverage crowns
there has been a lot of interest in the benefits of
such adhesive restorations, there is, as yet, little
clinical evidence in the literature to support their
use. As for extra coronal restorations, certain
modifications of tooth preparation such as including
additional bracing features in the area of the crack,
i.e., extending the preparation in a more apical
direction, beveling the cusps of the fractured
segment more than usual to minimize damaging
forces, using bases to prevent contact with the
internal surface of the casting, and using boxes and
grooves on the unfractured portion may help in
(20)
further reinforcement of the crack . with a history of CTS to reduce the risk of crack
(19)
Hood found that teeth restored with
amalgam overlays had fracture energies equal to
those of intact teeth. Widkop described the use of
cross-pinning; where pins are placed on either side
of the crack and the restorative material is packed
around these, binding the tooth structure together
MANAGEMENT OF CRACKED TEETH - CASE REPORTS
either side of the crack. However, if the cusp is left
unprotected, there is probably enough movement
to allow microleakage and a continuation of
symptoms. Some clinicians recommend the use of
reinforced glass ionomer cement (GIC) to hold the
cusps together. The bond strength of the GIC to hard
tissue is inadequate to withstand the forces to which
the tooth is subjected. Cracks extending
subgingivally often require a gingivectomy to
crown–root ratio may render the tooth unrestorable.
Where vertical cracks occur or where the crack
extends through the pulpal floor or below the level
of the alveolar bone, the prognosis is hopeless and
the tooth should be extracted followed by
replacement with an implant or a fixed bridge
(5, 18)
restoration .
. While
Awareness of the existence and etiology is
essential for its prevention. Cavities should be
prepared conservatively, internal line angles should
be rounded to avoid stress concentration, adequate
cuspal protection should be incorporated in the
design of cast restorations and they 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
(21, 24)
formation .
CONCLUSION
Fractures are the third most common cause of
tooth loss. Thus, it is of outstanding importance to
avoid or eliminate risk factors which contribute to
tooth fracture. The key factor is early diagnosis and
42
ENDODONTOLOGY
A. Pre-operative photograph
showing cracked left
maxillary first molar.
E. Pre-operative photograph
showing cracked left
mandibular first molar.
I. Pre-operative photograph
showing cracked right
maxillary first molar with
fracture line extending
buccolingually.
M. Tooth was bonded with
composite and prepared for a
metal crown.
B. Post obturation radiograph
shows satisfactory root canal
treatment.
F. Pre-operative radiograph
shows pulp exposure of the
left mandibular first molar.
J. Pre-operative radiograph of
the tooth with affected pulp.
N. Tooth finally restored with
a metal crown.
43
Neelam Mittal, Vishal Sharma, Anshu Minocha
C. A custom made metal
band was cemented to the
tooth.
G. Post obturation radiograph
with a band placed around the
tooth.
K. Root canal treatment was
done and a metal band placed
around the tooth.
O. Cracked right mandibular
first molar with a metal band
placed on it to prevent crack
propagation.
D. The tooth was bonded with
composite and finally restored
with a metal crown.
H. Tooth was bonded with
composite and restored with
a metal crown.
L. Post operative radiograph
showing satisfactory
obturation of the affected
tooth.
P.Tooth was bonded and
prepared to be restored with
a metal ceramic crown.
ENDODONTOLOGY
Q. The tooth finally restored
with a metal ceramic crown.
treatment of the crack so that they can be halted or
their progression slowed down. However, a cracked
tooth is a compromised tooth even with proper
treatment.
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