Cracks in Endodontics

CONTENT:-
 Introduction
 History
 Craze lines
 Fractured cusp
 Crack tooth syndrome
 Split tooth
 Overall Review

INTRODUCTION:-
 Tooth cracks and fractures are encountered daily by
dentist (31%).
 Root cracks and fractures can be two most frustrating
aspects of endodontic and restorative dentistry.
 Tooth fracture is commonly associated with impact
trauma.
 Crack and fractures are frequently the results of an
accumulating , un observed trauma
Longitudinal tooth cracks and fractures: an update and review ERIC M. RIVERA & RICHARD E. WALTON endodontic topic. 2015

HISTORY
1954 Gibb et al : Cusp fracture odantalgia
1956 Melion : A Fractured Cusp
1962 Sutton : Greenstick fracture of tooth crown
1964 Cammeron : Cracked Tooth Syndrome.
2001 Ellis : Incomplete tooth Fracture.

According To AAE-
CRAZE LINES
FRACTURED CUSP
CRACKED TOOTH
SPLIT TOOTH
VERTICAL ROOT
FRACTURE

CRAZE LINES
(Enamel infarction)

 Craze line affect only the enamel, originate on
the occlusal surface, are typically from occlusal
forces or thermocycling, and are asymptomatic
 CAUSES:-
-Biting on hard objects
- Tooth grinding
- From normal wear and tear .
- Extreme temperature changes
Berman LH, Kuttler S. Fracture necrosis: diagnosis, prognosis assessment, and treatment recommendations. J Endod 2010;36:442–6.
Craze lines

▪ In posterior teeth, usually evident crossing marginal
ridges and extending along buccal and lingual surfaces
▪ In anterior teeth, commonly long vertical craze lines
seen.
▪ Craze lines are frequently confused with cracks, but
can be differentiated by transillumination.
Craze lines

Worried about those crazy craze lines on your front teeth? Posted October 15, 2012 by James Fondriest, DDS, FACD, FICD & filed under Cosmetic Dentistry, Damaged Teeth.
Treatment planing:-
“According to Andrew Jordan craze lines are nothing to worry
about and usually do not require any treatment”
While craze lines are generally only Esthetic problems ,when stained
with tea or soda, get into the lines and cause staining.
It is generally not possible to scrub this out through normal tooth
brushing methods.
Various treatment modalities available are-
1) Teeth Whitening
2) Composite Restoration
3) Porcelain Veneers

Definition:-
Fractured cusp is defined as a complete or incomplete fracture initiated
from the crown of the tooth and extending subgingivally,; the fracture
usually involves at least two aspects of the cusp by crossing the marginal
ridge and also extending down facial or lingual groove.
- According to American association of endodontics.

- The fracture may involve both buccal or lingual cusps
on a molar.
- The fracture will extend to the cervical third of the
crown or root.
- Fractured cusps are relatively easy to diagnose and
treat with usually a good prognosis

Pathogenesis:-
A frequent cause of fractured cusps is inadequate dentin support of cusps
from extensive caries and/or large restorations
Silvestri AR Jr, Singh I. Treatment rationale of
fractured posterior teeth.J Am Dent
Assoc1978:97:806–810 ,1978
Larson et al.’ concluded that prepared teeth were more susceptible to
fracture than unprepared teeth and that the most influential factor was the
width of the occlusal portion of the preparation
Larson, T. D., Douglas. W. H., and Geistfeld, R. E.: Effect of
prepared cavities on the strength of teeth. Oper Dent 6:2.
1981

Cuspal fractures can be caused by forces put on existing restorations during
masticatory cycles; these forces stress the stress planes located apical to the cusps
that retain the restorations.
With an amalgam, the preparation axial walls converge toward the occlusal, so
occlusally directed forces on the restoration stress the cuspal stress planes.
The walls of an inlay preparation diverge toward the occlusal, so apically directed
forces stress the cuspal stress planes.
If we removes the restoration and observes the dried preparation surface, may
observe a crack line located at what was previously the apical-lateral aspect of the
restoration
Homewood CI. Cracked tooth syndrome – incidence, clinical
findings and treatment. Aust Dent J. 1998;43:217–22.
Panitvisai P, Messer HH. Cuspal deflection in molars in relation
to endodontic and restorative procedures. J Endod. 1995;21:57–61.

Clinical features
1) usually associated with wide and/or deep Class II restorations, or caries that have
weakened a marginal ridge.
2) Often a single cusp is involved and will include both a mesial-distal and a facial-lingual
component .
Therefore, the oblique, shearing fracture crosses the marginal ridge and extends down a
facial or lingual groove, often into the cervical region at or apical to the gingival margin
and epithelial attachment, usually not extending beyond the cervical third of the root
Reeh ES, Messer HH, Douglas WH. Reduction intooth stiffness as a result of
endodontic andrestorative procedures.J Endod1989:15: 512–516
Cavel WT, Kelsey WP, Blankenau RJ. An in vivo study of cuspal fracture.J Prosthet Dent1985:53:38–42.
Lagouvardos P, Sourai P, Douvitsas G. Coronal fractures in posterior teeth.Oper Dent1989:14:28–32

Diagnosis
SUBJECTIVE FINDINGS-
 Patient history – Most important tool for making diagnosis
- Frequently there is brief, sharp pain on mastication or with temperature,
particularly cold.
- Often the pain is more distinct upon masticatory release.
- Pain is neither severe nor spontaneous, only occurring upon stimulus.
-Interestingly, symptoms may be relieved when the cusp fractures off, likely
due to no further proprioceptive stimulation

OBJECTIVE TEST:-
RADIOGRAPH
PULP VITALITY TEST
TEST
BITING TEST
MAGNIFICATION
TRANSILLUMINATIO
ON

Radiographic findings
These are not often useful; cusp fractures are not usually
visible radiographically. If the entire cusp is missing,
there may be a “ghost” appearance on the radiograph.

2) BITING TEST:- – To Locate The Affected Tooth Using
Tooth
Slooth

Magnification– can be helpful when looking for a crack.
1) LOUPES 2) MICROSCOPE
• x16 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.

Transillumination test:-
The tooth is cleaned and a fiber-optic or other light source is applied directly
on the tooth.
Two main disadvantages of using transillumination without magnification are:
(a) Transillumination dramatizes all cracks to the point that craze lines appear
as structural cracks.
(b) Subtle color changes are indistinguishable
Lubisich EB, Hilton TJ, Ferracane J, Northwest Precedent. Cracked teeth: A review of the literature. J Esthet Restor Dent. 2010;22:158–67.

Treatment
Cracked Cusp Fractured
cusp
- Bonded composite
restoration.
- Full coverage crown or
onlay is recommended.
- Endodontic treatment- if
signs of pulp pathosis seen
-Fractured cusp that is mobile and
separable with wedging forces is usually
removed.
Small fragment
fracture
- Bonded composite
restoration.
Large fragment
fracture-
Full coverage crown
or onlay

Cracked tooth diagnosis and treatment: An alternative paradigm
John S. Mamoun1 and Donato Napoletano2 Eur J Dent. 2015 Apr-Jun; 9(2): 293–303
Cuspal fracture
completely supragingival
or no more tham 1-3mm
subgingivally.
- Polish the tooth and watch
without making a direct
restoration.
- Place direct restoration
- Place crown if remaining tooth
structure does not provide
enough retention to retain
direct restoration
Cuspal fracture with
fracture plane more than
3 mm subgingivally –
- Consider extraction.
- Restoration may be possible
with crown lengthening
surgery
- Endodontic treatment may be
needed if fracture plane
intersects pulp chamber.

Cracked teeth restored using direct composite resin showed that >90%
of teeth maintained pulp vitality after 7 years
At 7 years, no failures were recorded in the group with cuspal
coverage, whereas restorations without cuspal coverage showed a
mean annual failure rate of 6.0%, which was significantly different
from the group with cuspal coverage (log-rank test, P .008).
2008, JOE

Signore A, Benedicenti S, Covani U, et al. A 4- to 6-year retrospective clinical
study of cracked teeth restored with bonded indirect resin composite onlays. Int J
Prosthodont 2007;20:609–16.
Bonded indirect resin composite onlays for painful
cracked teeth have been reported to have a 6 year survival
rate of 93.02%

Definition:-
 Cracked tooth syndrome denotes an incomplete fracture of
tooth with a vital pulp. The fracture involves enamel and dentin,
often invoving the pulp.
American association of endodontics

Cracked teeth are also described as incomplete (greenstick)
fractures, or as tooth infractions ,which can be defined as an
incomplete tooth fracture extending partially through a tooth
Cracked tooth is a variation of the cusp fracture, but the
associated fracture is centered more occlusally.
The effects of cracked teeth tend to be more devastating because
their extent and direction are more centered and more apical
Bakland LK. Tooth infractions. In: Ingle JI, BaklandLK,
Baumgartner JC, eds.Ingle’s Endodontics,6thedn. Hamilton,
Ontario: BC Decker Inc., 2008:660–67

Analysis of Factors Associated with Cracked Teeth ,Deog-Gyu Seo et al, DDS, MS, PhD,* JOE , 2012
PREVELANCE
- An incidence rate of 34–74% has been documented
- Age range of 30–50 years, with a female predilection.
- 82.2% showed a sensitive reaction on the bite test.
Tooth usually involved
Maxillary first molar (28.0%),
Mandibular first molar (25.2%),
Mandibular second molar (20.6%),
Maxillary second molar (16.8%).

• Cracked tooth occurred mainly in
Restored Teeth- 72%, (class I restorations (39%)
Intact Teeth -28%
• Compared with resin (4.7%) or porcelain (0.9%), the use of nonbonded
inlay restoration materials such as gold (20.5%) or amalgam (18.7%)
increased the occurrence of longitudinal tooth fractures.
• In longitudinal fractured teeth, 30.8%- were treated endodontically
69.2%- were not.
Analysis of Factors Associated with Cracked Teeth ,Deog-Gyu Seo et al, DDS, MS, PhD,* JOE , 2012

Etiology:-
Restorative
procedures
Occlusal
factors
Developmental
factors
Miscellaneous
Factors
1. Inadequate
design features
2. stress
concentration
1- Masticatory
trauma
2. Trauma from
occlusion.
3. Functional
forces.
1. Parafunctional
habits.
2. Incomplete
fusion of area of
calcification
1. Thermal
cycling
2. Dental
instruments.

CLINICAL FEATURES:
• "Rebound pain" - is a consistent feature.
• Patients may or may not be able to locate the offending tooth .
• The absence of heat-induced sensitivity may also be a feature.
• Chronic pulpitis with no clinical symptoms may be seen as a result of micro-leakage of
bacterial by-products and toxins.
• Cracked tooth syndrome: Overview of literature 2015, Shamimul Hasan1, Kuldeep Singh2, Naseer Salati

Pathophysiology:-
• CTS is typically characterized by pain when releasing biting
pressure on an object
• When biting down the segments are usually moving apart and
thereby reducing the pressure in the nerves in the dentin of the
tooth.
• When the bite is released the "segments" snap back together
sharply increasing the pressure in the intradentin nerves causing
pain.
• The pain is often inconsistent, and frequently hard to reproduce.

Another theory states that:-
Pain on biting is caused by the 2
fractured sections of the tooth moving
independently of each other
Triggering sudden movement of fluid
within the dentinal tubules.
This activates A-type nociceptors in the
dentin-pulp complex, reported by the
pulp-dentin complex as pain
Banerji, S; Mehta, SB; Millar, BJ (May 22, 2010). "Cracked tooth syndrome. Part 1: aetiology and diagnosis". British Dental Journal.

Diagnosis
Dental history
 A thorough and detailed dental history may help in eliciting certain
distinct clues.
 The patient may have a history of long-term dental treatment, multiple
replacements of restorations, and occlusal adjustments.
 History of parafunctional habits
 History of cold sensitivity and sharp pain on biting hard or tough foods
which ceases when the pressure is released is an important indicator.
Homewood CI. Cracked tooth syndrome – incidence, clinical findings and treatment. Aust Dent J. 1998;43:217–22.

Clinical Examination
 Application of a sharp straight probe to the margins of the heavily restored tooth may
evoke sharp pain, indicative of the presence of underlying crack.
 Sometimes exploratory excavation may be needed to obtain a visual diagnosis. On
removal of the existing restorations, fracture lines may be revealed.
 Clinical examination may also reveal the presence of wear facets on the occlusal tooth
surfaces , occurrence of localized periodontal defects (where cracks extend subgingivally)
or the evocation of symptoms by sweet or thermal stimuli.

Periodontal probing
- Cracked tooth and a split tooth may be
differentiated by periodontal probing.
- The localized periodontal defect is the result
of a fracture line extending below the
gingiva.
- Isolated deep probing reveal the presence of
a split tooth, indicating a poor prognosis.

Investigations
Radiograph
Dye Test
Bite Test
Vitality
Transillumination

Radiographs
 Diagnosis of cracked tooth syndrome by radiographs is usually
questionable, as fractures propagate in a mesiodistal direction;
parallel to the plane of the film.
 Fractures occurring in a bucco-lingual direction is more readily
noticed on radiographs
 Radiographs may be helpful in assessing the status of the pulp
and periodontium, and for excluding other dental pathology.
Türp JC, Gobetti JP. The cracked tooth syndrome: An elusive diagnosis. J Am Dent Assoc 1996;127:1502-7.

Dye test
Special stains such as methylene blue or gentian violet are frequently
used to highlight the cracks.
Disadvantages:
1) Require placement of a provisional restoration.
This may weaken the tooth integrity and further
spread the crack.
2) Another disadvantage is difficult esthetic restoration
Liu HH, Sidhu SK. Cracked teeth – treatment rationale and case management: Case reports. Quintessence Int 1995;26:485-92.

Bite Test
 Pain on biting that increases after the pressure has been
withdrawn is a classical sign.
 Symptoms may be elicited when pressure is applied to an
individual cusp. This forms the basis of so-called "bite tests.“
 Here, the patient is asked to bite on various items such as a
toothpick, cotton roll, rubber abrasive wheels , orange
wooden stick or the commercially available Tooth Slooth.

Vitality tests
 Vitality tests for individual teeth are usually positive.
 Sometimes the affected teeth may show signs of
hypersensitivity to cold thermal stimuli due to the presence of
pulpal inflammation; a feature that may help to confirm a
diagnosis of cracked tooth syndrome.
 Teeth affected by the condition may be seldom tender on
apical percussion.
Trushkowsky R. Restoration of a cracked tooth with a bonded amalgam. Quintessence Int 1991;22:397-400.

Other diagnostic aids
Ultrasoundis also capable of imaging cracks in the simulated
tooth structure and can be used as a future diagnostic aid.
Indirect diagnostic measures, such as the use of copper rings,
acrylic provisional crowns, and stainless steel
orthodontic bands, may also be used to detect cracked tooth
syndrome.
Culjat MO, Singh RS, Brown ER, Neurgaonkar RR, Yoon DC, White SN. Ultrasound crack
detection in a simulated human tooth. Dentomaxillofac Radiol 2005;34:80-5.
Ehrmann EH, Tyas MJ. Cracked tooth syndrome: Diagnosis, treatment and correlation
between symptoms and post-extraction findings. Aust Dent J 1990;35:105-12.

 Another indirect diagnostic method is an unauthenticated technique
by Banerji et al.
 Composite resin is placed over the tooth without etching and
bonding. The patient feels marked improvement in discomfort on
biting, as the material acts as a splint.
Banerji S, Mehta SB, Millar BJ. Cracked tooth syndrome. Part 1: Aetiology and diagnosis. Br Dent J
2010;208:459-63.

Differentiating crack tooth from fractured
cusp and split tooth
• If a crack can be detected, use wedging to test for movement of the
segments to differentiate a cracked tooth from a fractured cusp or split
tooth.
• No movement implies a cracked tooth.
• May break off under slight pressure implies fractured cusp
• Mobility with wedging forces and the mobile segment extends well
below the cemento-enamel junction implies split tooth.

Treatment Plan
Small peripheral crack Large peripheral crack
Remove compromised portion
Restore with the following:-
1. Amalgam
2. Pinned amalgam
3. Composite
4. Cast restoration
No pulpal
involvement
Pulpal
involvement
Pulpal involvement but
crack extending below
alveolar bone
Interim restoration with orthodontic band

No pulpal
involvement
Pulpal
involvement
Pulpal involvement but
crack extending below
alveolar bone
Permanent
stabilization and
cuspal protection
Root canal
treatment
Root canal
treatment
Bonded
restoration
Cast
restoration
External and internal
reinforcement using fibre
reinforced composite
Mta placement
Full coverage crown
Composite
Pins
Amalgam
Inlay
Onlay
Full crown

Prognosis
 According to Clark and Caughman-
 Excellent: (a) Cuspal fractures within the dentin that angle from the
faciopulpal or linguopulpal line angle of a cusp to the
cemento-enamel junction or slightly below.
(b) Horizontal fracture of a cusp not involving the pulp
 Good: A coronal vertical fracture that runs mesiodistally into the dentin
but not into the pulp
Clark LL, Caughman WF. Restorative treatment for the cracked tooth. Oper Dent 1984;9:136-42.

 Poor: A coronal vertical fracture that runs mesiodistally into
the dentin and pulp, but is limited to the crown
 Hopeless: A coronal vertical fracture that runs mesiodistally
through the pulp and extends into the root.
Clark LL, Caughman WF. Restorative treatment for the cracked tooth. Oper Dent 1984;9:136-42.

Int Endod J. 2006 Nov;39(11):886-9
Within the limitations of this study, the 2-year survival rate of root-
filled cracked teeth was 85.5%. Multiple cracks, terminal teeth and pre-
treatment pocketing were significant prognostic factors for survival of
root filled cracked teeth.

The term “split tooth” is defined as a complete fracture initiated from
the crown and extending subgingivally, usually directed mesio
distally extending through both of the marginal ridges and through
the proximal surfaces.
-According to American association of endodontics
Definition:-

• The fracture is located coronally and extends from the crown
to the proximal root.
• A split tooth is the evolution (end result) of a cracked tooth.
• The root surface involved is in the middle or apical third.
There are no dentin connections; tooth segments are now
entirely separate .
• The split may occur suddenly, but it more likely results from
long-term growth of a cracked tooth

Two major causes are:-
Pathogenesis:-
1) Probably persistent
destructive wedging or
displacing forces on existing
restorations.
2) New traumatic forces
that exceed the elastic
limits of the remaining
intact dentin.

• These are primarily mesiodistal fractures that cross both marginal ridges
and extend deep to shear onto the root surfaces.
• The more centered the fracture occlusally, the greater the tendency to
extend apically.
• These fractures are more devastating. Mobility (or separation) of one or
both segments is present.
• These fractures usually include the pulp. The more centered the fracture,
the greater the probability of exposure.
Clinical Features

Diagnosis
Subjective findings:-
• Commonly, the patient reports marked pain on mastication.
• These teeth tend to be less painful with occlusal centric
contacts than with mastication.
• A periodontal abscess may be present, often resulting in
mistaken diagnosis.

Objective tests :-
Radiographic Findings:-
Findings on radiographs depend partially on pulp status but
are more likely to reflect damage to the periodontium.
Often there is marked horizontal loss of interproximal or
interradicular bone; this may have the appearance of a “U-
shaped” furcation lesion.
The fracture line, which is usually mesial distal, is not
visible.

1) Removal of restoration
With split tooth the fracture line is usually readily visible under or
adjacent to the restoration; it includes the occlusal surface and both
marginal ridges.
2) Wedging :-
To determine whether segments are separable is also important .
As with cracked tooth, an instrument is placed in the cavity
Wedging against the walls is done with moderate pressure; the
walls are then visualized for separation .
A separating movement indicates a through-and-through fracture
Other Findings:-

• Periodontal probing generally shows deep defects;
probings tend to be adjacent to the fracture.
• Again, due to the usual location of these fractures
mesially or distally, an eight point probing depth
utilization is encouraged.
3) Periodontal probing:-

Treatment:-
Crack extending cervically or
middle third of root
Crack extending apically
Extraxction
• If smaller segment mobile-
Remove the segment
• Remaining tooth structure
salvaged

Different approaches to maintenance are used, depending on conditions.
Some choices are:-
Remove the fractured
segment
Retain the fracture segment
temporarily
Remove the fractured
segment and perform crown
lengthening and orthodontic
extrusion
Remove the fracture segment
and perform no further
treatment
1. 2.
3. 4.

Retain the fractured segment temporarily :-
• First, a rubber dam is applied with a strong rubber dam clamp to isolate and hold the
segments together.
• Root canal treatment is completed , and restoration with a retentive amalcore
(onlaying the undermined cusps) or bonded restoration is performed.
• Then the fractured segment is removed.
• Granulation tissue proliferates to occupy the space and reattach the periodontium to
the root dentin surface.
• The final restoration usually is the amalcore but may be a full crown with a margin
related to the new attachment.

Remove the fractured segment and perform crown lengthening or
orthodontic extrusion:-
• The mobile segment is removed first; root canal treatment is performed
next, followed by crown lengthening or orthodontic extrusion and
placement of an appropriate restoration.

Remove the fractured segment and perform no further
treatment :-
• This choice is appropriate when root canal treatment has been completed
previously and the tooth already restored.
• All pulp space areas must be filled to the margins with permanent
restorative material (e.g., amalgam) with no root canal filling material
(e.g., gutta-percha or Resilon) exposed.
• The defect usually granulates in, and reattachment to the fractured dentin
surface occurs.

Chief complaint:- A male patient, 19 years of age, came with chief complaint of
multiple fractured teeth in both upper and lower jaws causing pain and discomfort for
the last two weeks
History:- History of trauma two weeks ago due to injury by hand pump handle
Intraoral examination:- Revealed longitudinal fractures involving 27, 37, and 46

• On visual inspection of 27, the fracture line was running mesiodistally
involving both the marginal ridges
• The fracture segments cannot be displaced, but they can be visualized
by wedging with a probe
• The fracture line had extended subgingivally through the pulp
chamber into the furcation area.
• An intraoral periapical radiograph revealed that lamina dura of
mesiobuccal and distobuccal root was involved.
• Fracture line was not appreciable on the radiograph.
• It was diagnosed as a split tooth of 27 involving the pulpal floor.

• On examination of the lower left quadrant, there was a fracture of a
mesiobuccal cusp with respect to 37.
• The fracture line had both mesiodistal and buccolingual components.
• Both fractured segments were in position but can be visualized by
exploring with a probe
• Further, the subgingival extent of fracture line was 1 mm below the
cementoenamel junction (CEJ), and it was not involving the pulp chamber.
• The tooth was not mobile and not tender on percussion. Vitality test was
positive.
• It was diagnosed as fractured mesiobuccal cusp with respect to 37, not
involving the pulp.

• On examination of the lower right quadrant, there was a
fracture of mesiolingual cusp with respect to 46.
• The fractured segments were not displaced but could be
separated by exploration with the probe.
• Further, the fracture line was extending up to the coronal third
of the root surface, without involving the pulpal floor
• Periodontium was not compromised along the fracture line and
percussion test was negative. Vitality test was positive.
Intraoral periapical radiograph revealed fracture line.
• It was diagnosed as fractured mesiolingual cusp with respect to
46.

Management of split tooth c 27

Immediately after the diagnosis, the tooth was
stabilized using orthodontic band (RMO 0.180 ×
0.005 mm)
In the same appointment, endodontic treatment
was initiated. Fracture line was cleaned of any
debris with 30% H2O2
The biomechanical preparation was done using
Rotary V-Taper (30/0.04%) (SS White)
single cone gutta-percha obturation using MTA
Fillapex, as the root canal sealer, was completed.
Mineral Trioxide Aggregate (ProRoot MTA,
Dentsply, DeTrey, Germany) was placed on the pulpal
floor at the fracture site where dentine was missing.

In the next appointment, temporary restoration was
removed and access cavity was thoroughly debrided
with saline and dried.
From each canal, 3 mm of gutta-percha was removed
with Peeso Reamer size-3
Three pieces of 1 cm Ribbond (Ribbond Inc., USA) fibre
were taken. The root canal orifices were etched and
rinsed and bonding agent was applied
Into each of the three canals, 3 mm of Ribbond fibres
was inserted and was stabilized in the root canal with
the help of flowable composite and cured
After curing, around 7 mm of remaining fibres was kept
outside the canal orifice. Then, these fibres were spread
on the floor of the pulp chamber and intermingled to
create a meshwork for the internal reinforcement

A flowable composite was placed over this fibrous
meshwork and manipulated slightly with the help of
plastic instrument
subsequently, core buildup composite (Tetric
Ceram Ivoclar Vivadent, Germany) was done.
After 15 days, the orthodontic band was removed
and crown preparation was done. Temporary
crown was cemented which was later replaced by
metal ceramic crown

Management of Fractured Mesiobuccal Cusp c 37

Fractured
Mesiobuccal
Cusp In 37 Was
Removed
Carefully
Tooth Preparation
Was Done For
Class II Cast
Metal Inlay With
Cusp Capping.
Tooth Preparation
Was Extended
More Apically,
And An Indirect
Pattern Was
Fabricated
Cast Gold Inlay
Was Fabricated,
Luted Using Glass
Ionomer Cement
Type I And
Checked
Radiographically

Management of fractured mesiolingual
cusp c 46

• As the fracture line was not involving the pulp chamber
in 46 but was extending subgingivally, and tooth was
vital initially, the fractured cusp was not removed
• Instead it was bonded with the help of composite resin
and stabilized with orthodontic band
• On subsequent appointment, the tooth had become
nonvital and a sinus tract had also appeared in its
relation.
• Hence, endodontic treatment was completed
• Internal and external reinforcement were achieved in
the same manner as mentioned for tooth 27

Classification Origin Direction Symptoms Pulp status Prognosis
Craze line Crown Variable Asymptomatic Vital Excellent
Fractured cusp Crown Mesiodistal or
faciolingual
Mild and
mostly on biting
and cold
Usually vital Good
Crack tooth Crown Mesiodistal
often central
Acute pain on
biting
occasional
sharp pain to
cold
Variable Questionable
Split tooth Crown and root Mesiodistal Marked pain on
chewing
Often root filled Poor- unless
crack subsides
subgingivally
Vertical root
fracture
Root Faciolingual Vague pain
mimicking
periodontal
Mostly root
filled
Poor- root
resection in
multi rooted
Overall review

Cracks in Endodontics

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