management of cracked teeth

8/14/2019 Management of Cracked Teeth

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ENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGY

Management of cracked teeth - a case report

Neelam Mittal *

Vishal Sharma **Anshu Minocha ***

* 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.

INTRODUCTION

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

fracture with subsequent pulpitis (2). The term

cracked tooth syndrome was coined by Cameron

in 1964. Camerons 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 advocateduse 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,

Luebke considered fractures as either complete or

incomplete (5).

The most common cause of an incompletefracture is masticatory or accidental trauma.

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 factorslike 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.

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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 patients 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.


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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 (6, 7).

Diagnosis is a difficult task, sharp pain onchewing 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

Caufields analysis of crack lines under a scanning

electron microscope demonstrated that the width

of the fracture plane can be less than (8). Magnifying

glasses, transillumination, staining with methyleneblue are useful in visualizing cracks (8, 12). Now a

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

and periodontal status of teeth (6, 7, 10, and 11).

The primary goal is to splint and stabilize a

cracked tooth to prevent further extension or

complete fracture of the tooth.

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.

Clinical examination revealed fractured right

maxillary first molar with the fracture line runningbuccolingually 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

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 painand 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

MANAGEMENT OF CRACKED TEETH - CASE REPORTS


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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, asuperficial 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

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 notcause 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

Neelam Mittal, Vishal Sharma, Anshu Minocha


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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

root canal treatment (22).

Permanent stabilization can be achieved with

an adhesive intracoronal restoration e.g., bondedamalgam, 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

protection, and full-coverage crowns (14-17). While

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, certainmodifications 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

further reinforcement of the crack(20)

.

Hood (19) 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

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

expose the margin; however, an unfavourable

crownroot 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

restoration (5, 18).

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, adequatecuspal 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

with a history of CTS to reduce the risk of crackformation (21, 24).

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



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A. Pre-operative photographshowing cracked leftmaxillary first molar.

B. Post obturation radiographshows satisfactory root canaltreatment.

C. A custom made metalband was cemented to thetooth.

D. The tooth was bonded withcomposite and finally restoredwith a metal crown.

E. Pre-operative photographshowing cracked leftmandibular first molar.

F. Pre-operative radiographshows pulp exposure of theleft mandibular first molar.

G. Post obturation radiographwith a band placed around thetooth.

H. Tooth was bonded withcomposite and restored witha metal crown.

I. Pre-operative photographshowing cracked rightmaxillary first molar withfracture line extendingbuccolingually.

J. Pre-operative radiograph ofthe tooth with affected pulp.

K. Root canal treatment wasdone and a metal band placedaround the tooth.

L. Post operative radiographshowing satisfactoryobturation of the affectedtooth.

M. Tooth was bonded withcomposite and prepared for ametal crown.

O. Cracked right mandibularfirst molar with a metal bandplaced on it to prevent crackpropagation.

P.Tooth was bonded andprepared to be restored witha metal ceramic crown.

N. Tooth finally restored witha metal crown.

Neelam Mittal, Vishal Sharma, Anshu MinochaENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGY


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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.

References:

1. Gibbs JW. Cuspal fracture odontalgia. Dent Digest

1954;60:158-160.

2. Ritchey B, Mendenhall R, Orban B. Pulpitis resulting from

incomplete tooth fracture. Oral Surg 1957; 10:665-670.

3. Cameron CE. Cracked-tooth syndrome. J Am Dent Assoc

1964; 68:405-411.

4.Maxwell E H, Braly B V. Incomplete tooth fracture: Prediction

and prevention.J Calif Dent Assoc 1977; 5: 51-55.

5. Luebke R G. Vertical crown-root fractures in posterior teeth.

Dent Clinic North Am 1984; 28: 883-894.

6. Byoung-Duck, Young-Eun Lee. Analysis of 154 cases of teeth

with cracks Dental Traumatology 2006; 22:118.

7. C. I. Homewood Cracked tooth syndrome Incidence,

clinical findings and treatment Australian Dental Journal 1998;

43:4.

8. Arens DE Introduction to magnification in endodontics. J

Esthet Restor Dent 2003; 15(7):426-39.

9. MO Culjat, RS Singh, ER Brown, RR Neurgaonkar, DC Yoon

and SN White. Ultrasound crack detection in a simulated human

tooth. Dentomaxillofacial Radiology 2005; 34:80-85.

10. Rosen H. Cracked tooth syndrome. J Prosthet Dent 1982;

47:36-43.

11. Geurtsen W. The cracked-tooth syndrome-Clinical features

and case reports. Int J Periodontics Restorative Dent 1992;

12:395-405

12. Ellis S G S, McCord J F, Burke F J T. Predisposing and

contributing factors for complete and incomplete tooth

fractures. Dent Update 1999; 26: 150-158.

13. Ehrmann EH, Tyas MT. Cracked tooth syndrome: diagnosis,

treatment and correlation between symptoms and post-

extraction findings.Aust Dent J 1990; 35(2):105-12.

14. Bremer DB, Geurtsen W. Fracture resistance of human

molars after adhesive restoration with ceramic inlays or

composite resin fillings. Am J Dent 2001; 14:216-220.

15. Geurtsen W, Garcia-Godoy F. Bonded restorations for the

prevention and treatment of the cracked-tooth syndrome. Am

J Dent 1999; 12:266-270.

16. Trushkowsky R. Restoration of a cracked tooth with a

bonded amalgam. Quintessence Int 1991; 22(5):397-400.

17. Davis R, Overton JD. Efficacy of bonded and nonbonded

amalgam in the treatment of teeth with incomplete fractures. J

Am Dent Assoc. 2000; 131(7); 848-52.

18. Dewberry JA. Vertical fractures of posterior teeth. In: Weine

FS (ed). Endodontic Therapy, ed 5. St Louis: Mosby, 1996;71-

81.

19. Hiatt WH. Incomplete crown-root fracture in pulpal-

periodontal disease. J Periodontal 1973; 44:369-379.

20. Casciari BJ. Altered preparation design for cracked teeth.J

Am Dent Assoc 1999; 130(4):571-2.

21. Agar JR, Weller RN. Occlusal adjustment for initial

treatment and prevention of the cracked tooth syndrome. J

Prosthet Dent 1988; 60(2):145-7.

22. Gutmann J L, Rakusin H. Endodontic and restorative

management of incompletely fractured molar teeth. Int Endo J

1994; 27: 343-348.

23. Ingle J I, Bakland L K. Endodontics. 4th edn, Philadelphia:

Williams and Wilkins, 1994; 364-65, 537-38.

24. Geurtsen W, Schwarze T, Gunay H. Diagnosis, therapy

and prevention of cracked tooth syndrome. Quintessence Int

2003; 34(6):409-17.


Q. The tooth finally restoredwith a metal ceramic crown.

management of cracked teeth

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