|DENTAL SCIENCE - CASE REPORT
|Year : 2015 | Volume
| Issue : 6 | Page : 700-703
Cracked tooth syndrome: A report of three cases
Kadandale Sadasiva1, Sathishmuthukumar Ramalingam2, Krishnaraj Rajaram3, Alagappan Meiyappan4
1 Department of Conservative Dentistry and Endodontics, Chettinad Dental College and Research Institute, Kelambakkam, Chennai, Tamil Nadu, India
2 Department of Oral and Maxillofacial Pathology, Chettinad Dental College and Research Institute, Kelambakkam, Chennai, Tamil Nadu, India
3 Department of Orthodontics and Dentofacial Orthopaedics, SRM Dental College, Chennai, Tamil Nadu, India
4 Department of Oral and Maxillofacial Surgery, Chettinad Dental College and Research Institute, Kelambakkam, Chennai, Tamil Nadu, India
|Date of Submission||28-Apr-2015|
|Date of Decision||28-Apr-2015|
|Date of Acceptance||22-May-2015|
|Date of Web Publication||1-Sep-2015|
Department of Conservative Dentistry and Endodontics, Chettinad Dental College and Research Institute, Kelambakkam, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Cracked tooth syndrome (CTS), the term was coined by Cameron in 1964, which refers to an incomplete fracture of a vital posterior tooth extending to the dentin and occasionally into the pulp. CTS has always been a nightmare to the patient because of its unpredictable symptoms and a diagnostic dilemma for the dental practitioner due to its variable, bizarre clinical presentation. The treatment planning and management of CTS has also given problems and challenges the dentist as there is no specific treatment option. The management of CTS varies from one case to another or from one tooth to another in the same individual based on the severity of the symptoms and depth of tooth structure involved. After all, the prognosis of such tooth is still questionable and requires continuous evaluation. This article aims at presenting a series three cases of CTS with an overview on the clinical presentation, diagnosis and the different treatment options that varies from one case to another.
Keywords: Green stick fracture, hairline fracture, incomplete fracture, split tooth syndrome
|How to cite this article:|
Sadasiva K, Ramalingam S, Rajaram K, Meiyappan A. Cracked tooth syndrome: A report of three cases. J Pharm Bioall Sci 2015;7, Suppl S2:700-3
In 1964, Cameron introduced a new terminology to the field of dentistry known as "cracked tooth syndrome (CTS)." He used the term to describe a clinical condition which is characterized by an incomplete fracture of a vital posterior tooth extending to the dentin and occasionally into the pulp.  The diagnosis of CTS has been embarrassing to a dental practitioner as the condition presents an incomplete history, nonspecific symptom, and unidentifiable sign during clinical examination and routine radiographic projections.  Although a fracture line may run in mesiodistal direction on the occlusal surface of the tooth, the depth of the fracture plane and its orientation through the tooth structure is not evident.  The fracture may continue to involve the pulp, root dentin and cementum communicating with the periodontal space later if not earlier. In this article, we submit three cases of CTS with an overview on the clinical presentation, diagnosis, and the different treatment options that varies from one and other.
| Cases Reports|| |
A 57-year-old aged male reported to the dental clinic with a chief complaint of severe pain on the right lower posterior tooth region for past 2 days. The patient was able to localize the pain to the right mandibular first molar. Clinical examination revealed mild attrition with slight tenderness on percussion in 46. No significant change was evident in the radiograph. The tooth was checked for vitality with electrical pulp test and test cavity preparation. The tooth did not respond to both the test and so root canal therapy was initiated which relieved the pain. The following 2 days was uneventful, but the patient reported on the 3 rd day with fracture of the tooth. The fracture was oriented in a mesiodistal direction and was incomplete [Figure 1]a and b. The root canal therapy was completed and a composite core with flowable and hybrid composite uniting fractured segments mimicking monobloc concept. The procedure was completed with the insertion of a full coverage metal ceramic crown [Figure 2]a and b. The tooth was observed at regular intervals and a 6 months follow-up done clinically and radiographically revealed no significant abnormality [Figure 3]a and b.
|Figure 1: (a) Fracture line running mesiodistally in 46, (b) Preoperative radiograph of 46|
Click here to view
|Figure 2: (a) Post-endodontic picture showing composite core build-up, crown preparation (b) Full metal ceramic crown in 46|
Click here to view
|Figure 3: (a) Postoperative radiograph of 46 at 6 months, (b) Postoperative at 6 months follow-up and clinically healthy gingiva|
Click here to view
The patient was a 57-year-old male with complaints of sensitivity and occasional pain in the right mandibular second molar. Examination revealed no evidence of deep dental caries, pulpal or periodontal pathology. Visual examination using a magnifying loupe with LED light (×3.5) [Figure 4]. It revealed a crack propagating from the central fissure; crossing over the distal marginal ridge covering the distal surface of 47 was detected as 48 was missing. The tooth responded positively to vitality test. The objective to preserve the pulp and stabilization of the cracked tooth was achieved with light cure flowable composite to seal the crack and hybrid composite resin for external restoration [Figure 5]a-c.
|Figure 5: (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|
Click here to view
A 42-year-old aged male reported with complains of pain in 46 which had a large silver amalgam filling. Radiograph of the tooth revealed secondary caries with pulp involvement. Root canal therapy was planned and initiated. During the subsequent visit, the patient presented with a fractured tooth which propagating mesiodistally and vertically deep into the floor of the pulp chamber which evident with the help of apex locator. The case was considered for extraction and the postextraction specimen revealed a longitudinal fracture involving the crown, root furcation, and up to the apex [Figure 6]a-c.
|Figure 6: (a) Fractured in 46 seen involving the chamber, (b) Preoperative radiograph, 46 showing carious lesion, and fractured amalgam restoration, (c) Extracted tooth showing vertical fracture|
Click here to view
| Discussion|| |
The American associations of endodontist categorized tooth fracture into five types: Craze line, cuspal fracture, cracked tooth, split tooth, and vertical root fracture. Another manner by which a tooth fracture can be classified are, (a) tooth infractions which include the craze line, cracked tooth and cuspal fracture, and (b) vertical root fracture which is associated with an root canal treated tooth. Tooth infractions are incomplete tooth fracture that extends partially through a tooth commonly involving the enamel, dentin, and sometimes the pulp and periodontal structure. Tooth infraction is also known as incomplete tooth fracture, CTS, split tooth syndrome, greenstick fracture, hairline fracture or cuspal fracture odontologia. 
They are mainly seen in patients in the age range of 30-50 years. The commonly involved teeth are in the order of mandibular second molar, mandibular first molar, and the maxillary premolar. The entire patients in our observation were aged above 40 years and had the involvement of the mandibular molars which could be attributed to the "lever" effect due to their close proximity to the temporomandibular joint.  The cracks are usually oriented in a mesiodistal direction as was in our cases but may run in a buccolingual axis in case of mandibular molars.  The number of reported cases of CTS is said to have increased in the past few years although the incidence rate is much higher than what said because of the inability to diagnose or misdiagnose during the early course of the lesion. The lesion has a poor identity due to an inadequate and bizarre clinical presentation. The initial lesion causes frustration to both, the dentist, and the patient because of the difficulty to localize the pain. The most common complaint is pain on chewing in an otherwise asymptomatic tooth. Such pain subsides when the pressure is released. The affected teeth responds positive to vitality test, but the pulp may undergo necrosis in late lesion.  They may respond to thermal changes, especially to cold and sensitivity to sweets. They do not have a specific cause, but they are commonly associated with large, complex restorations, poor cavity design and restoration, pin retained restoration, tooth with brittle enamel and dentin, tooth structure loss like abrasion, erosion and caries, high masticatory force, bruxism, acute trauma to tooth, and accidental biting on a hard object ridge. , Teeth with class I restoration or those decayed and unrestored are more vulnerable for CTS as presented in our cases. This may be as a result of an occluding plunger cusp on its marginal.  The patient may give a history of recurrent restoration and occlusal correction but an inconclusive treatment. In the case, one of our presentations the tooth was nonvital and crack was not found during the first visit. The crack propagated following the initiation of the endodontic treatment which indicates meticulous application of technique is required during endodontic therapy. Factors like excessive access cavity and canal preparation, excessive condensational force, wedging of instrument and restorative materials, excessive usage of rotary, and ultrasonic instruments can make their contribution in the development/propagation of crack during endodontic treatment. 
The diagnosis can be aided with the use of magnifying loupes for visualization, a sharp explorer for tactile examination or to elicit catch, excavation of the suspected area or by exploring the old restoration to expose the crack. A periodontal probing will differentiate a crack from a split tooth as the latter is associated with deep periodontal pocket and has a poor prognosis. Dye test using gentian violet or methylene blue may be performed to visualize the crack. The most common method in the diagnosis of CTS is the trans-illumination test using a fiber-optic light source and a magnifier to enhance visualization. A clinical microscope used at ×16 magnification is proven to be a diagnostic aid in the detection of crack. ,
Pain can be elicited by wedging or by opening the cleave under pressure, this can be performed by asking the patient to bite on an orange wood stick, cotton roll, rubber abrasive wheel or on a 10 size round bur or using the commercially available tooth slooth. A diagnostic radiograph is of no use unless when the crack is oriented in a buccolingual direction and on the other hand they aid in evaluating the periodontal status of the tooth involved.  The treatment should always be preceded by ruling out pains of other origin like pulpal, periodontal and periapical inflammation, galvanism, psychogenic, and other orofacial pain disorders. 
The management of CTS varies from one case to another or from one tooth to another in the same individual based on the severity of the symptoms and depth of tooth structure involved. After all, the prognosis of such tooth is still questionable and requires continuous evaluation. The major goal in the treatment of a crack tooth is to preserve the vitality and protection with stabilization of the affected structure. These objectives can be achieved by providing an intracoronal adhesive restoration like bonded amalgam, composite resin or with an extracoronal restoration like full coverage crown, onlay, and three-quarter crown. A peripherally located crack is relatively small, superficial and so do not involve the pulp. Such tooth can be restored conventionally after fracture-off the affected segment.  In the second case of our presentation, the tooth had a peripheral crack and tested positive for vitality. Hence, priority was given to preserve the pulp and fracture was stabilized with composite resin restoration.
The centrally located cracks are large or involve the pulp. The large central cracks need stabilization of the weak crown structure with an orthodontic band and occlusal clearance that renders pain relief. Another treatment option for such situation is to give a full coverage crown for stabilization. The tooth is assessed after 2-4 weeks to check for an irreversible pulp pathology, which if present an endodontic treatment is indicated. ,, Extraction of the tooth is indicated when the cracks are vertical and progresses to involve the furcation or into the alveolar bone. ,, In one of the three cases presented in this article, the tooth was extracted due to vertical fracture.
| Conclusion|| |
The diagnosis and management of CTS are dilemmatic to a dental practitioner. Various techniques have been put forth in the management of CTS after taking care of the clinical considerations and prognosis. All attempts should be made to preserve, stabilize, and protect the affected tooth although the end result of any treatment modality advocated is a matter to wait on watch.
Financial support and sponsorship
Conflict of interest
There are no conflict of interest.
| References|| |
Cameron CE. Cracked-tooth syndrome. J Am Dent Assoc 1964;68:405-11.
Banerji S, Mehta SB, Millar BJ. Cracked tooth syndrome. Part 1: Aetiology and diagnosis. Br Dent J 2010;208:459-63.
Lynch CD, McConnell RJ. The cracked tooth syndrome. J Can Dent Assoc 2002;68:470-5.
Nisha G, Amit G. Textbook of Endodontics. 3 rd
ed. New Delhi: Jaypee Brothers Medical Publishers; 2014. p. 524-30.
Chandra BS, Gopikrishna V. Grossman's Endodontic Practice. 13 th
ed. New Delhi: Wolters Kluwer (India); 2014. p. 146-9.
Mathew S, Thangavel B, Mathew CA, Kailasam S, Kumaravadivel K, Das A. Diagnosis of cracked tooth syndrome. J Pharm Bioall Sci 2012;4(Suppl S2):242-4.
Gutmann JL, Rakusin H. Endodontic and restorative management of incompletely fractured molar teeth. Int Endod J 1994;27:343-8.
Türp JC, Gobetti JP. The cracked tooth syndrome: An elusive diagnosis. J Am Dent Assoc 1996;127:1502-7.
Ehrmann EH, Tyas MJ. Cracked tooth syndrome: Diagnosis, treatment and correlation between symptoms and post-extraction findings. Aust Dent J 1990;35:105-12.
Swepston JH, Miller AW. The incompletely fractured tooth. J Prosthet Dent 1986;55:413-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]