Morning

A 45 years old male patient came with chief

complain of severe pain in the lower left
region
Pain is aggravated when chewing foods
The pain is absence in absence of functional
movement of the left jaw
IOPA is non-contributory
Scaling was done since the region was
present with heavy calculus.

 Patient

comes back two days later . The

pain didn't subside even after
meticulous scaling was done. The pain is
relieved with administration of
diclofenac sodium.

What

could be your diagnosis?

 On

further probing, patient revealed

history of accidental biting of stone
when eating few days back

What

is the diagnosis?

Tooth
infraction
Wan Mohd Asyraf
111323026
Siti Sarah
111323027

Definition

Incomplete tooth fracture extending partially

through a tooth Nisha Garg

A crack of the enamel wihout loss of tooth

structure American Assosciation of
Endodontics ( AAE )

Synonyms of tooth
infractions

Incomplete tooth fracture

Cracked tooth syndrome

Split tooth syndrome

Green stick fracture

Hairline fracture

Cuspal fracture odontalgia

Types of tooth fracture

Craze line : It is confined to enamel only

Cuspal fracture : Diagonal fracture not involving

pulp

Cracked tooth : Incomplete vertical fracture

Vertical root fracture : Complete longitudinal

fracture , usually seen in endodontically treated
tooth

Craze line

Cuspal fracture

Etiology

Etiology is not specific

Commonly seen in teeth with large and

complex restorations

Most common tooth to fracture is mandibular

molars

Etiology > large and

complex restorations

Etiology > Extensive use

of pins for restorations

Etiology - Deep abrasion,

erosion and caries

Etiology > Accidental

biting on hard tooth

Etiology > Trauma to the

tooth

Etiology
1.

Extensively large restoration

2.

Improper design

3.

Excessive use of pin for restoration

4.

Age changes in enamel and dentin causing

tooth to be more brittle

5.

Deep abrasion, erosion and caries

6.

Accidental biting on hard object

7.

High masticatory forces

8.

Oral habit bruxism

9.

Acute trauma to the tooth

Classification of cracked
tooth

Class A : Crack involving enamel and dentin but

not pulp

Class B : Crack involving pulp but no

periodontal problem

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

Complication of tooth
fracture
1.

Cracked tooth progression to split tooth

2.

Severe pain

3.

Fracture with pulp involvement may progress

to periapical pathosis

So, what do I need to do??

These steps include :

Dental History
Periodontal
Probing
Subjective
Examination
Radiographic
Examination
Objective Visual
Examination
Restoration
Removal
Tactile

Staining
Periapical Tests
Transillumination
Bite Tests
Wedging Forces
Vitality Testing
Surgical
Assessment

Investigati
ons

Visual
inspection
Percussion
Bite test
Periodontal
probing
Wedging
forces
Radiograph

Investigations

Visual inspection:

magnifying lenses
Transillumination
staining with suitable agents (for example, iodine,
methylene blue or gentian violet dye).

Percussing the affected area of the tooth (for

example, the specific cusp)
Asking the patient to bite a firm object, such as
orange, wood sticks, cotton rolls, rubber abrasive
wheels or similar devices.
Periodontal probing can help establish the diagnosis
of CTS when the fracture line extends subgingivally,

Magnifying lenses

Transillumination

Dye test

Bite test (Tooth slooth test)

Periodontal probing

C/O: Problems in brushing the teeth in

this area.
-Necrotic pulp
-Deep periodontal pocket
-Bone destruction on mesial and distal
sides.

Wedging forces

Radiographic examination

How to manage?

Depends on the severity, extent, location, pulpal

and periapical involvement

Craze line

Do not need to be restored except for possibly

cosmetic purposes

Cuspal fracture

Depending upon the amount of remaining tooth

structure

Remove the affected cusp

Restore with a direct or a cuspal-reinforced restoration
(full crown or onlay) that covers the crack margin.
Dentin and enamel bonding with adhesive resins, if
placed with special techniques, have been shown to
reinforce a weakened tooth structure and provide
cuspal protection.
Root canal treatment or vital pulp therapy: the crack
affects the pulp chamber or has resulted in irreversible
pulpitis

Cracked tooth

Vary depending on the location

and extent of the crack may be
helpful in determining when to
recommend extraction with
replacement by a fixed or
removable bridge, or an implant.

Also depends on determination of

pulpal and periapical diagnosis.

If a crack is evident on the cavity

floor and/or proximal external
surface, the following should be
considered

Cavity Floor Removal of the fracture line only in the area of

the cavity floor that would include the initiation of an ideal
endodontic access opening is helpful in determining the apical
extent of the crack and whether the pulp is involved. However,
keep in mind that the fracture is small and invisible at its
furthest extent (even after staining), and likely continues
deeper into the dentin than can be visualized.
Proximal Surface Removal of the fracture line on the
proximal external surface portion of the tooth below the level
of CEJ is not usually indicated. More information on the extent
of the crack may be obtained, but it also is likely to cause the
tooth to become nonrestorable. Removal of the proximal
marginal ridge and tooth structure associated with the fracture
takes away sound tooth structure, thereby decreasing tooth
strength and resistance to fracture. However, keep in mind that
not removing the crack on the proximal surface may allow
bacterial penetration to continue, which could eventually lead
to the need for root canal treatment or extraction

Prognosis

The patient should be fully informed that the

prognosis is questionable
A study done in 2007 evaluated 127 patients
with teeth diagnosed with reversible pulpitis
that had a cracked tooth. The treatment was
placement of a crown restoration without
performing root canal treatment. 20% of these
cases converted to irreversible pulpitis or
necrosis within six months and required root
canal treatment, with none of the other teeth
requiring root canal treatment over a six-year
evaluation period.

Vertical fracture

Patients with VRFs typically present with

minimal signs and symptoms.
The recommended treatment is almost
exclusively extraction or removal of the
cracked or fractured root(in multirooted
tooth).

Precautions

The cardinal rules for safety are to:

1. Avoid excessive removal of intraradicular dentin

2. Minimize internal wedging forces.
Compaction/condensation of root canal filling
materials should be carefully controlled.
Posts weaken roots and should not be used unless
they are necessary to retain a foundation.

What can I do to prevent my teeth from

cracking?

Dont chew on hard objects; ice, popcorn

kernels

Dont clench or grind your teeth

If you clench or grind your teeth during sleep,

talk to your dentist about getting a
retainer/mouthguard/night guard.

Wear a mouthguard when playing contact

sports

References

Textbook of endodontics, Nisha Garg , 2nd

edition

http
://www.ncbi.nlm.nih.gov/pmc/articles/PMC38701
47/table/T1
/

https://
www.aae.org/uploadedfiles/publications_and_re
search/endodontics_colleagues_for_excellence_
newsletter/ecfesum08.pdf
http://
www.drotterholt.com/CrazeCrackFracture.html