Cracked Tooth Syndrome: Detailed Explanation!!

CRACKED TOOTH SYNDROME

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The term ‘cuspal fracture odontalgia’ was first used by Gibbs in 1954, to describe a condition which is better now known as ‘cracked tooth syndrome’ or ‘cracked cusp syndrome’. The latter concept was coined by Cameron in 1964.

Cracked Tooth Syndrome is defined as an incomplete fracture of a tooth with a vital pulp. The fracture involves enamel and dentin, often involving the dental pulp.

Cracked Tooth Syndrome

In more recent times the definition has been amended to include, ‘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

In the late 1970s, Maxwell and Braly advocated the use of the term incomplete tooth fracture. According to Luebke, fractures are either complete or incomplete, although, other terms such as

• Incomplete tooth fracture

• Cracked tooth syndrome

• Split tooth syndrome

• Green stick fracture

• Hairline fracture

• Cuspal fracture odontalgia are also known.

Classification of Cracked Tooth Syndrome

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.

Cracked teeth can be classified on the basis of pulpal or periodontal involvement and the extent of crack.

Class A: Crack involving enamel and dentin but not pulp.

Class B: Crack involving pulp but not periodontal apparatus.

Class C: Crack extending to pulp and involving periodontal apparatus.

Class D: Complete division of tooth with pulpal and periodontal apparatus involvement.

Class E: Apically induced fracture

Two classic patterns of crack formation exist:

1. The first occurs when the crack is centrally located, and following the dentinal tubules may extend to the pulp.

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

Prevalence

1. The condition presents mainly in patients aged between 30 and 50 years

2. Early epidemiological survey by Cameron in 1976 seemed to suggest that the condition was much more prevalent among female dental patients. more recent studies that both sexes seem to be equally affected.

3. Most cases occur in teeth with class I restorations (39%) or in those that are unrestored (25%)

4. Mandibular molars (2^nd > 1^st molar) are most commonly affected, followed by maxillary premolars and maxillary molars, while mandibular premolar teeth seem to be least affected.

5. Lower first molar teeth are usually the first permanent teeth to erupt into the dental arch, they are most likely to be affected by the condition of dental caries, followed by the

need of subsequent restorative intervention. Also wedging effect’ inflicted upon lower first molar teeth from the prominent mesio-palatal cusp of maxillary first molar teeth may also be contributory.

6. The transverse ridge of the maxillary molars may provide structural reinforcement and account for the lower incidence of fracture in these teeth.

7. According to Homewood, fractures tend to occur in a direction parallel to the forces on the cuspal incline.

8. It has also been suggested that most cracks tend to run vertically (as opposed to horizontally) and usually run in a mesio-distal direction along the occlusal surface and may involve one or both of the marginal ridges respectively

Etiology/Causes of Cracked Tooth Syndrome

1. The aetiology of incomplete fractures of posterior teeth is multi-factorial. In an article by Guersten et al.

2. Lynch et al. have subdivided the causes of cracks into four major causative categories, hence: ‘restorative procedures’, ‘occlusal factors’, ‘developmental conditions’ and ‘miscellaneous factors.

Clinical Symptoms of Cracked Tooth Syndrome

1. Sharp pain when biting, or when consuming cold food/beverages. Pain increases as the applied occlusal force is raised

2. Sensitive for years because of an incomplete fracture of enamel and dentin that produces only mild pain.

3. Other symptoms may include pain on release of pressure when fibrous foods are eaten, ‘rebound pain’

4. Eventually, this pain becomes severe when the fracture involves the pulp chamber also. With the involvement of pulp, Pulpal and Periodontal symptoms may occur.

5. Tooth is sensitive to Cold and Sweets. The absence of heat induced sensitivity may also be a feature

The type, duration and the stimuli of pain has important implications for both diagnosis and treatment.

The Commonly Signs and Symptoms are-

Luebke suggested the following terms to diagnose pain from a cracked tooth:

1. Dentin pain - A brief, sharp twinge.

2. Pulpal pain - The deep, demanding, radiating pain precipitated by thermal shock to an inflamed pulp. The pain at times may be spontaneous.

3. Periodontal pain - The aggravating throbbing of a sore tooth

Diagnosis

Diagnosing CTS has been a challenge to dental practitioners and is a source of frustration for both the dentist and the patient

The ease of diagnosis varies according to the position and extent of the fracture. Mandibular molars (2^nd > 1^st) and maxillary premolars are the most commonly affected teeth. The tooth often has an extensive intracoronal restoration.

Dental History

History of dental treatment involving repeated occlusal adjustments or replacement of restorations, which fail to eliminate symptoms.

The patient will give a history of pain on biting on a particular tooth, often occurring with foods that have small, discrete, harder particles in them, for example, bread with hard seeds or muesli.

Clinical Examination

Includes the presence of facets (identifies teeth involved in eccentric contact and at risk from damaging lateral forces)

The presence of localized periodontal defects (found where cracks extend subgingivally),

Symptoms on sweet or thermal stimuli.

Removing existing restorations and stains aid in the visualization of the crack.

Visual Examination

Visual inspection of the tooth is useful, but cracks are not often visible without the aid of magnifying loupes.

Tactile Examination

one should gently pass the tip of sharp explorer along the tooth surface, it may catch the crack.

Exploratory Excavation      

Aids in Visual Diagnosis .

Consent of the patient should be taken before excavation since it is not guaranteed that a fracture will be found underneath any removed restoration.

Removal of existing restorations may reveal fracture lines.

Percussion Test

They are seldom tender to percussion (when percussed apically).

Periodontal Probing

With the help of periodontal probing, one can distinguish between a cracked tooth and a split tooth when the fracture line extends below the gingiva, thereby causing a localized periodontal defect.

Careful probing must be performed to disclose the presence of an isolated periodontal pocket.

However, isolated deep probing often indicates the presence of split tooth, which predicts a poor prognosis.

Dye Test

Various dyes like Gentian Violet or methylene blue stains can be used to highlight fracture lines. The disadvantage of this technique is that it takes at least 2-5 days to be effective and may require placement of a provisional restoration.

Transillumination

The use of fiberoptic light to transilluminate a fracture line is also a method of diagnosing cracked tooth syndrome.

Transillumination is probably the most common modality for traditional crack diagnosis.

There are two drawbacks to using transillumination without magnification.

First, transillumination dramatizes all cracks to the point that craze lines appear as structural cracks.

Second, subtle color changes are rendered invisible.

Transillumination with a fiber-optic light and use of magnification will aid in visualization of a crack.

Bite Test

Orange wood stick, rubber wheel or the tooth slooth are commonly used for detection of cracked tooth.

Tooth slooth is small pyramid shaped, plastic bite block with small concavity at the apex which is placed over the cusp and patient is asked to bite upon it with moderate pressure and release.

The pain during biting or chewing especially upon the release of pressure is classic sign of cracked tooth syndrome.

Commercially available diagnostic tools to undertake ‘bite tests’ include products such as ‘Fractfinder’ and ‘Tooth Slooth II’

Radiographs

Radiographs are not of much help especially, if, crack is mesiodistal in direction. Even the buccolingual cracks will only appear if there is actual separation of the segments or the crack happens to coincide with the X-ray beam.

Taking radiographs from more than one angle can help in locating the crack

Microscopic Detection

Experienced clinicians using a clinical microscope have reached a general consensus that ×16 provides an ideal magnification level for the evaluation of enamel cracks, with a range from ×14 to ×18.

Use of the clinical microscope makes possible the treatment of asymptomatic but structurally unsound posterior teeth.

 Surgical Exposure

If a fracture is suspected, a full thickness mucoperiosteal flap should be reflected for visual examination of root surface.

Treatment/Management of Cracked Tooth Syndrome

Urgent care of the cracked tooth involves the immediate reduction of its occlusal contacts by selective grinding of tooth at the site of the crack or its antagonist.

Definitive treatment of the cracked tooth aims to preserve the pulpal vitality by providing full occlusal coverage for cusp protection.

When crack involves the pulpal floor, endodontic access is needed but one should not make attempts to chase down the extent of crack with a bur, because the crack may become invisible long before it terminates.

Endodontic treatment can alleviate irreversible pulpal symptoms.

If the crack is partially visible across the floor of the chamber, the tooth may be bonded with a temporary crown or orthodontic band. This will aid in determining the prognosis of the tooth and protect it from further deterioration till the endodontic therapy is completed.

A decision flowchart of treatment options is presented

 Prevention

• Awareness of the existence and etiology of cracked tooth syndrome 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 cracked tooth syndrome to reduce the risk of crack formation