CRACKED TOOTH SYNDROME

Dr Vijay Salvi

We all come across apparently healthy teeth eliciting complex and often bizarre
symptoms. The patient will give a long history of undiagnosed but severe pain,
and of treatments which failed to provide relief. These symptoms can be attributed
to a “cracked” tooth.
This article describes the signs and symptoms, diagnostic techniques,
classification and management to what is universally referred to as “Cracked
Tooth Syndrome”. The article will describe those cracks that may have involved
the underlying dentin and has the potential to propagate further to the pulp and/or
periodontal structure culminating in a fractured tooth but will not refer to
superficial enamel cracks which may be secondary to trauma, stress or iatrogenic
in nature.

People are living longer and keeping their teeth longer. As a result, patients are more
likely to have complex restorative and endodontic procedures leaving teeth more
susceptible to cracks. Stressful lifestyle resulting in parafunctional habits suc h as
clenching and bruxism and consumption of paan, betel nut etc. are important
contributory factors. Additionally, in recent years, practitioners have been more aware of
the existence of cracks and, therefore, diagnose more cracks.
The key to saving a cracked tooth is to be aware of the characteristic signs and
symptoms , diagnose the crack as early in its development as possible and initiate
appropriate treatment without delay.

CLASSIC SIGNS, CLASSIC CONFUSION

Teeth with cracks elicit erratic pain on mastication, especially with release of biting
pressure and/or pain to extremes of temperature, especially cold. Generally, there is no
pain to percussion, and radiographs are inconclusive. Often patients give history of pain
which has been difficult to diagnose and of treatment/s which has failed to relieve their
symptoms. Depending on the location, direction, and extent of the crack, the patient may
present any one or all of these signs and symptoms making diagnosis confusing.
If the pulp is involved, there may be signs and symptoms of irreversible pulpitis or
necrosis with periradicular pathosis. If the crack extends to a root surface, there may be
a periodontal defect.
Many times, cracks go unnoticed until a variety of symptoms are present, a restoration is
removed, or a significant periodontal defect is identified. If caught and treated
appropriately, many cracks can be stopped or at least slowed down from propagating
further, preventing loss of the tooth. Steps should be taken immediately to confirm the
presence of a crack, determine the type of crack, and formulate an appropriate treatment
plan.

DIAGNOSTIC PROTOCOL FOR DETECTION OF CRACKS:

In a tooth suspected of having a crack it is important to know if the tooth has undergone
endodontic procedure. A cracked root canaled tooth will exhibit only those signs and
symptoms associated with periodontal breakdown secondary to crack propagation.
Teeth with vital pulp will require further investigations to determine the health of pulp and
periodontium once a crack is diagnosed.
• Dental History
A detailed dental history which includes dietary habits, bruxism and clenching of teeth is
a must. Check for a history of previous cracked teeth as many anatomical and
behavioral factors that predispose teeth to crack affect more than one tooth.
History of periodontal disease with extensive bone loss in the area can be an important
pointer to diagnosis as decreased bone support has been thought to lead to increased
stress on dentin, predisposing the roots of a tooth to cracking. History of any previous
trauma can be useful in detecting a cracked tooth.

• Visual examination:
Start with the face, checking for enlarged jaw muscles indicating excessive stress on
mastication indicating paranormal functions. Check for wear facets, and any steep cusps
or developmental grooves which may predispose teeth to cracks. Finally, check teeth
surfaces carefully in a dry field. Note any craze lines or darker cracks. Generally, the
darker the stain in a crack, the longer the crack has been present. Also check the
cracked restorations or unusual gaps between restorations and tooth structure. Clinical
microscope or enhanced magnification and illumination can be helpful in visual
identification of a crack.

• Tactile examination
Gently run the tip of a sharp explorer along the tooth surface. The tip may catch in a
crack. Palpate the gingiva around the tooth, checking for possible evidence of an
underlying dehiscence or fenestration typical of a vertical root fracture.

• Bite tests
Use a rubber wheel, wood stick, or other commercially available instruments (such as
Tooth Slooth® fracture detector (Professional Results, Inc . CA USA). Place the
instrument on each cusp or fossa and ask the patient to bite down with moderate
pressure and release. Test several teeth and cusps. Be sure to use controls. Pain during
biting or chewing is considered a classic symptom and may be the only conclusive
evidence early in the crack’s development. The absence of pain during biting, however,
does not rule out the possibility of a crack.

• Periodontal probing
Thorough probing in small increments around the entire circumference of the tooth may
reveal a narrow periodontal pocket. The narrow pocket that forms along a crack will
restrict side to side motion of the probe, making it easy to differentiate from the broad
based defect characteristic of a periodontal disease pocket.

• Staining
Cracks may be disclosed through staining (Figs 1 and 2). A dye, such as methylene
blue, Seek (Ultradent products Inc.), or To-dye-for (Roydent Dental Products) can be
applied to the external tooth surface, in the cavity after restoration removal, or on a
surgically exposed root.
Figs 1 and 2. Crack disclosed in a molar by staining with a caries detector

• Transillumination
In transillumination, a fiber-optic or other similar light source is applied directly to the
tooth surface. The light beam is positioned perpendicular to the plane of the suspected
crack. A crack will block the light. Structurally sound teeth, including those with “craze
lines”, will transmit the light throughout the crown.

• Radiographs
Cracks rarely show on radiographs. Mesio-distal crac ks can never be seen, and bucco-
lingual cracks will only appear if there is actual separation of the segments or the crack
happens to coincide with the X-ray beam. Changes in the pulp chamber, canal or
periradicular space, however, may suggest the presence of a crack. Radiographic
evidence tends to be conclusive as the crack progresses and a bony defect develops.
Taking periapical X rays from more than one angle and taking bite-wings may increase
the chance of catching a crack- induced defect early in its development (Figs 3 and 4).

Figs. 3 & 4. The patient presented with H/O inability to chew on right side. On
examination no abnormalities were detected. Radiograph reveals a healthy tooth with no
caries and healthy bone architecture, indicating good periodontal health. However, a
periapical lesion with apparently no etiology is indicative of a cracked tooth. Note
generalized occlusal wear.

A thickened periodontal ligament space or a diffuse radioluscency, especially one with

an elliptical shape in the apical area, may indicate a crack. Check also for restorations
held in place by dentinal pins, which can predispose teeth to cracking.
In root canaled teeth, rare but significant findings include a radio opaque line where
gutta percha or sealer has been expressed into the crack during obturation. A consistent
radiolucent line along the length of the root canal filling material may indicate space
caused by a crack but should not be considered conclusive, because it could be caused
by other factors. Root canal sealer expressed in a horizontal plane within the apical third
of the root is strongly indicative of a rot fracture.
Check root canaled teeth for long posts, short-wide posts, custom metal posts, or posts
with threads that bind with tooth structure, as the size, design and placement of posts
often contribute to cracks.

• Restoration removal
This allows for vis ual examination of the cavity. Carefully check the mesial and distal
marginal ridges, which tend to be weak areas. Magnification and staining can be helpful.

• Surgical assessment
Surgical exploration allows for visual examination of the root surface for the appearance
of a crack and should only be used if the crack is highly suspected and cannot be
confirmed by other diagnostic means. Performing diagnostic surgery, however, can help
early detection of untreatable situations, sparing the need for endodontic or restorative
treatment on an ultimately hopeless case. A consultation with an endodontist or
periodontist may be advisable prior to surgical assessment. Whenever a surgery is
performed to detect a crack, the patient should be fully informed that it is a diagnostic
procedure.

CRACK TYPES AND CLASSIFICATION

Inconsistent terms have led to confusion in classification. This article proposes a
classification for cracked teeth based on absence or presence of pulpal and periodontal
apparatus involvement and the extent of crack making treatment planning and prognosis
of the affected tooth simpler.
The proposed classification is as under:
♦ Class A - Crack involving Enamel and Dentin but NOT involving pulp
♦ Class B - Incomplete fracture of Crown extending to the pulp but NOT involving
periodontal apparatus
♦ Class C - Incomplete fracture of crown extending to the pulp and involving
periodontal apparatus
♦ Class D - Complete division of tooth with pulpal and periodontal apparatus
involvement
♦ Class E - Apically induced fractures.

Classification Involvement of Involvement Involvement Initiation Prognosis

Enamel/Dentin of Pulp of Perio. of crack
Apparatus
Class A YES NO MAYBE CORONAL EXCELLENT
Class B YES YES NO CORONAL GOOD
Class C YES YES YES CORONAL AVERAGE
Class D YES YES YES CORONAL POOR
Class E ROOT YES YES APICAL POOR
INVOLVEMENT
Class A
FRACTURED CUSPS AND ENAMEL CRACKS

Class A cusp fractures are the easiest to diagnose and has the best prognosis,
especially when the crack does not extend below the gingival attachment. The fractured
cusp usually results from a lack of cusp support due to a weakened marginal ridge.
Occlusally, it is common for the crack to have both a mesio-distal and a bucco-lingual
component. The crack will cross the marginal ridge-frequently weakened by a restoration
or caries - and continue down a buccal or lingual groove in apical direction. It may
terminate parallel to the gingival margin or slightly subgingivally.
Generally, only one cusp is affected. Pain- occasionally associated with sensitivity- is
mild. Bite tests will elicit brief, sharp pain, especially with release of biting pressure. The
pulp is usually vital. Radiographs are inconclusive. The affected cusp may break off
during restoration removal, possibly resulting in relief of symptoms when the cusp
breaks off. When present on a root canaled tooth, the discomfort is minimal except when
the fracture line extends subgingivally.
Treatment:
The tooth is treated by removing the affected cusp and restoring the tooth with a full
crown that covers the crack margin. Root canal treatment is necessary only in the rare
event when the crack affects the pulp chamber or has resulted in irreversible pulpitis.
Correction of causative factors of crack is essential.
Frequently a tooth will show a mesio-distally oriented crack arising from the occlusal
surface advancing apically. These cracks may terminate above the CE junction, but
frequently will cross the CEJ to continue apically (Figs 5 and 6). If detected early, it is
important that these cracks are treated before they spread and involve the pulp or the
periodontium. Prognosis is excellent with a bonded restoration.

Figs 5 and 6 A lower second molar revealed a crack arising from an old restoration and
advancing apically- on exploration it turned out to be a class A crack.

Class B and C
CRACKED TOOTH
The crack runs from occlusal surface apically without separation of the two segments.
Occlusally, the crack is more centered than a cusp fracture and, therefore, more likely to
cause pulpal and periradicular pathosis as it extends apically. The crack may cross
either or both marginal ridges and is more often mesiodistal, shearing toward the
lingual/palatal root surface (Fig 7). Rarely, the crack may be buccal-lingual in mandibular
molars.
The signs and symptoms of a cracked tooth will vary significantly depending on the
progress of the crack.

Fig 7. A Crack running mesio-distally on a upper left first premolar. This crack on further
examination turned out to be a class C crack.

Differential diagnosis: The crack will probably be invisible to the naked eye and
impossible to disclose with staining initially. The cracked tooth may only exhibit acute
pain on chewing or sharp, brief pain to cold. The restorative history of the tooth, while
diagnostically helpful for cusp fracture, is not as helpful with cracked tooth. Restorations
can contribute to cracked tooth, and the crack may be evident across the cavity floor
after a restoration is removed. However, unrestored teeth that are free of caries and
teeth with conservative restorations frequently experience these cracks. Teeth with
class1 restorations crack as frequently as those with class 2 restorations.

If a crack can be detected, gently test for movement of the segments to differentiate a
cracked tooth from a fractured cusp (class A) or split tooth (class D). A fractured cusp or
a split tooth may break off under slight pressure while the segments of a cracked tooth
(Class B or C) will remain in place.
Position of the crack may also help differentiate a cracked tooth from a fractured cusp.
Tooth crack occurs more toward the centre of the occlusal surface as compared to the
cusp fracture which is more peripheral in position. More centered cracks tend to go
deeper toward the apex before completely separating the tooth into two segments.
If the crack has progressed to involve the pulp or periodontal tissue, the patient may
have thermal sensitivity that lingers after removal of the stimulus or slight to very severe
spontaneous pain consistent with irreversible pulpitis, pulp necrosis, or apical
periodontitis. There may even be pulp necrosis with periradicular pathosis.

Treatment planning: The cracked tooth treatment plan will vary depending on the
location and extent of the crack. Even when the crack can be located, the extent is still
difficult to determine. Endodontic treatment is often indicated, followed by a full crown to
bind the cracked segments and protect the cusps. However, many factors can affect
prognosis, and each of these must be carefully considered before proceeding with
treatment. These include:
Periodontal probing:
• Absence of a defect does not rule out the presence of a crack.
• Deep probing indicates an adverse prognosis.
Radiographic examination:
• Findings will depend on pulpal and periradicular status but are usually not significant.
• Vertical or furcal bone loss may indicate a severe crack.
Pulp and periradicular tests:
• If pain on chewing is the only symptom, a tight-fitting band or temporary crown may
be cemented to help confirm a cracked tooth diagnosis. The band serves as a splint,
holding the crack together. If banding resolves pain on chewing, a full coverage
restoration may keep the tooth pain free. If pain continues after banding, further
evaluation of the extent of the crack and pulpal and periradicular status should be
performed.
• Any thermal sensitivity probably indicates pulp involvement, and root canal treatment
will be necessary prior to restoring the tooth with a crown.
Endodontic access:
• The practitioner may choose to create an endodontic access to determine whether
the pulpal floor is cracked. However, an attempt should not be made to chase down
the extent of the crack with a bur, because the crack becomes invisible long before it
terminates and sound dentin will be sacrificed unnecessarily. Staining the access
cavity may help disclose the crack. Magnification and illumination may help confirm
the presence of a crack on the pulpal floor.

Fig 8 & 9: A lower molar with a class B crack running along distal half of the floor.
Binding of the cracked segments during the endodontic procedure will improve the
overall prognosis of the tooth. The segments in this case have dentinal pins (Filpin, S J
Filhol Dental Mfg Ltd., Ireland) placed and area bonded with resin restorative material
after identifying the canals but before biomechanical preparation and obturation. A tight-
fitting band or temporary crown will serve the same purpose as the dentinal pins.

• If the crack is partially visible across the floor of the chamber, the tooth may be
banded with a temporary crown or orthodontic band. This will aid in determining the
prognosis of the tooth and protect it from further deterioration till endodontic therapy is
completed and a permanent restoration placed.
 Fig 10 Fig 11

Fig 12 Fig 13 Fig 14

Figs. 10, 11 radiographs of tooth no 36. Fig 12 class C incomplete crack along the
floor of the same tooth. Fig 13 after endodontic therapy and restorative management
and, fig 14 with final restoration. A crown will be placed after clinical and radiological
evidence of improved periodontal status.

• If the crack runs across the full width of the floor, the prognosis is poor. An extraction
may be considered. If the crack line runs bucco-lingually in a lower molar or involving a
single root in an upper molar, a resection of the separated root may be advisable in a
strategically important tooth. Prognosis is hopeless in a tooth where the crack line
extends to the full length of the floor and has a large periodontal defect associated with
it.

Class D
SPLIT TOOTH
The prognosis of a tooth that has split is very poor to hopeless and the entire cannot be
saved. These cracks are usually mesio-distal, across both marginal ridges, split the tooth
into two segments , and usually is the final stage of progression of a cracked tooth. A
split tooth is easily identified by a crack line running across the tooth, usually mesio-
distally, with the two segments easily separable with a probe. The patient will complain
of pain on chewing and soreness of the gums of the affected area. Periodontal
involvement, however, may result in mistaken diagnosis of periodontal abscess.
In a few cases of split tooth, the smaller fractured segment can be removed and the
remaining segment restored. If the crack extends apically to a significant extent, than the
extraction of the segment may leave a large periodontal defect, in which case an
extraction may be the only remedy. (Fig 15 and 16)

Figs 15 and 16 complete crack of upper molar involving attachment apparatus

Class E
VERTICAL ROOT FRACTURE [VRF]
Vertical root fractures begin in the apical third of the root, usually in the bucco-lingual
plane, extending to varying distance in the coronal direction. The crack may or may not
extend to both buccal and lingual surfaces. VRF occurs almost exclusively on root
canaled tooth. Chief etiological factors are iatrogenic viz. overzealous instrumentation or
condensation during obturation and placement of post. VRF present with very few signs
and symptoms, hence go unnoticed till periapical or periradicular pathology develops. At
that stage it can mimic a failing root canal treatment or a periodontal abscess. The
treatment is usually extraction; hence, a conclusive diagnosis is important.
Patient may present with mild signs and symptoms. The tooth may or may not be
mobile, x-rays do not give a conclusive picture except occasionally, in case of separation
of a segment. Widening or breakdown of periodontal space from apical to coronal
direction may be indicative of a VRF. Periodontal probing can be helpful as the crack
may occur at any level along the root and may not reach from apical to cervical.
However, most will allow deep probing in narrow or rectangular patterns typical of a
cracked tooth lesion. Deep probing may be only on the facial or the lingual aspect or on
both. Some VRFs show normal probing patterns. Percussion and palpation tests may be
inconclusive.

Surgical assessment: Vertical root fracture may require surgical inspection for
conclusive diagnosis. When soft tissue is reflected, a “punched-out” oblong bony defect
filled with granulomatous tissue overlying the root is characteristic. The defect may be a
dehiscence or a fenestration. When the inflammatory tissue is removed, the crack is
usually evident. In some cases, a crack may be detected when a resected root end is
examined under magnification. Even if the crack is not readily detectable, the
characteristic bony defect is usually considered conclusive evidence.

Treatment: Depending on the type of tooth affected, VRF treatment may involve
extraction, root resection or hemisection.
To conclude, it may be stated that diagnosis of a cracked tooth can be difficult,
but there is no doubt that it must be done with a sense of urgency. Establishing a
diagnosis of a cracked tooth to your patient’s elusive problem satisfies the
patient’s reasons for having sought your expe rtise and helps in initiating
appropriate treatment plan.