cracked tooth syndrome

1. Cracked tooth syndrome
Dr. Nuha Elkadiki
(lecturer in Conservative Dentistry and Endodontic Department
,Faculty of Dentistry ,University Of Benghazi )

2.  Cracked tooth syndrome (CTS) is
where a tooth has incompletely
cracked but no part of the tooth
has yet broken off. Sometimes it
is described as a greenstick
fracture.
Tooth crack in the upper first molar tooth in a patient who
suffers from bruxism.

3. Classification and definition
Cracked tooth syndrome could be considered a type of dental
trauma and also one of the possible causes of dental pain.
Cracked tooth syndrome is "a fracture plane of unknown depth
and direction passing through tooth structure that, if not already
involving, may progress to communicate with the pulp and/or
periodontal ligament."

4. Signs and symptoms
Sharp pain when biting on a certain tooth, which may get worse if the
applied biting force is increased. Sometimes the pain on biting occurs
when the food being chewed is soft with harder elements, e.g.
seeded bread.
"Rebound pain" i.e. sharp, fleeting pain occurring when the biting
force is released from the tooth,
Sharp pain when drinking cold beverages or eating cold foods, lack
of pain with heat stimuli.

5. Signs and symptoms
Pain when eating or drinking sugary substances.
Sometimes the pain is well localized, and the individual is able
to determine the exact tooth from which the symptoms are
originating, but not always.
If the crack propagates into the pulp, irreversible pulpitis, pulpal
necrosis and periapical periodontitis may develop, with the
respective associated symptoms.

6. Pathophysiology
CTS is typically characterized by pain when releasing biting pressure
on an object. This is because 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.
If untreated, CTS can lead to severe pain, possible pulpal death,
abscess, and even the loss of the tooth.

7. Pathophysiology
If the fracture propagates into the pulp, this is termed a
complete fracture, and pulpitis and pulp death may occur. If the
crack propagates further into the root, a periodontal defect may
develop, or even a vertical root fracture.

8. Pathophysiology
According to one theory, the 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.
Another theory is that the pain upon cold
stimuli results from leak of noxious
substances via the crack, irritating the pulp.
Crack (vertical fracture) of tooth and root #
(green arrows) splitting it in two even pieces
which has caused a lateral periodontal
abscess (blue arrows).

9. Diagnosis
 The diagnosis of cracked tooth syndrome is notoriously difficult even for
experienced clinicians.
 The features are highly variable and may mimic sinusitis, temporomandibular
disorders, headaches, ear pain, or atypical facial pain/atypical odontalgia
(persistent idiopathic facial pain).
 A detailed history may reveal pain on release of pressure when eating or sharp
pain when consuming cold food and drink. There are a variety of habits which
predispose patients to CTS including chewing ice, pens and hard sweets etc.
 Recurrent occlusal adjustment of restorations due to discomfort may also be
indicative of CTS, alongside a history of extensive dental treatment.

10. Techniques used for diagnosing CTS
Clinical examination:
 Cracks are difficult to see during a clinical exam which may limit diagnosis.
 However other , clinical signs which may lead to the diagnosis of CTS includes:
1. Wear faceting indicating excessive forces perhaps from clenching or grinding .
2. Presence of an isolated deep periodontal pocket which may symbolize a split
tooth.
3. Removing restorations may help to visualize fracture lines but should only be
carried out after gaining informed consent from the patient.
4. Tactile examination with a sharp probe may also aid diagnosis.

11. Gentian Violet or Methylene Blue Stains
 Dyes may be used to aid visualization of fractures. The
technique requires 2–5 days to be effective and a
temporary restoration may be required. The structural
integrity can be weakened by this method, leading to
crack propagation.
Techniques used for diagnosing CTS

12. Transillumination
 Transillumination of tooth , showing vertical fracture
(blue arrows) and inflammation in marginal gingiva at
fracture site (green arrow)
 Transillumination is best performed by placing a fibre
optic light source directly onto the tooth and optimal
results can be achieved with the aid of magnification.
Cracks involving dentine interrupt the light
transmission.
Techniques used for diagnosing CTS

13. Radiographs
Radiographs offer little benefit in visualizing
cracks( This is due to the fact that cracks
propagate in a direction which is parallel to the
plane of the film) (Mesio-distal)
Techniques used for diagnosing CTS

14. Bite Test
o Patients bite down followed by sudden
release of pressure.
o CTS diagnosis is confirmed by pain on
release of pressure.
o The involved cusp can be determined
by biting on individual cusps separately.
Tooth Slooth II
Techniques used for diagnosing CTS

15. Microscopic Detection
Experienced clinicians using a clinical
microscope have reached a general
consensus that ×16 provides an ideal
magnification level for the evaluation
of enamel cracks, with a range from .
Techniques used for diagnosing CTS

16. Epidemiology
CTS is multifactorial, the causative factors include:
previous restorative procedures.
occlusal factors; patients who suffer from bruxism, or clenching are
prone to have cracked teeth.
developmental conditions/anatomical considerations.
1.trauma
2.others, e.g., aging dentition or presence of lingual tongue studs.

17. Treatments
There is no universally accepted
treatment strategy, but, generally,
treatments aim to prevent movement of
the segments of the involved tooth so
they do not move or flex independently
during biting and grinding and so the
crack is not propagated.
Stabilization (core buildup) (a
composite bonded restoration placed in
the tooth or a band is placed around
the tooth to minimize flexing)
Fractured tooth (blue arrows)
viewed in the mouth (left) and
after extraction (right).

18. Treatments
Crown restoration (to do the
same as above but more
permanently and predictably)
Root Canal therapy (if pain
persists after above)
Extraction