Endodontics

Cracked Tooth Syndrome-Decoding the Enigma

Dr. Suhani Patel
P.G. Student

Dr. Dipti Choksi

Abstract
Cracked tooth syndrome is a diagnostic enigma to many practitioners. This article is with
the aim to shed light on the understanding cracked tooth syndrome as a condition in itself by
focusing on areas like type of crack, its clinical features, diagnosis and management of
cracked tooth syndrome (CTS). The condition refers to an incomplete fracture of a vital
posterior tooth that occasionally extends into the pulp. A lack of awareness of the condition
coupled with its varied clinical features can make diagnosis of CTS difficult. Common
symptoms include an uncomfortable sensation or pain from a tooth that occurs while
chewing hard foods and which ceases when the pressure is withdrawn. The patient is often
unable to identify the offending tooth or quadrant involved, and may report a history of
numerous dental procedures with unsatisfactory results. Successful diagnosis and
management requires an awareness of the existence of CTS and the appropriate diagnostic
tests. Management options depend on the nature of the symptoms and extent of the lesion.
These options include routine monitoring, occlusal adjustments, placement of a cast
restoration and endodontic treatment.
Key Words: cracked tooth syndrome; cracked tooth therapy; crack lines; craze type of
crack tooth.
Introduction
he term cracked tooth syndrome
(CTS) refers to an incomplete
fracture of a vital posterior tooth
that involves the dentin and occasionally
extends into the pulp.1-3 The term Cracked
tooth syndrome was coined in 1964 by
Cameron3. The basis of the term was
attributed to the correlation between
occurrence of CTS and size of restoration.
Ellis et al (1991) describes it as 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.7
Incidence & Patterns of Cracked Tooth
Syndrome (CTS)
Incidence of CTS is more often in 30-50
years of age.8-10 This condition has equal
gender predilection.11
Mandibular second molars, followed by
mandibular first molars and maxillary
premolars, are the most commonly affected
teeth.2,12 While the crack tends to have a
mesio-distal orientation in most teeth, it may
run buccolingually in mandibular molars.11
CTS manifests two classic patterns of
crack formation-1
1. The first occurs when the crack is
centrally located, and following the
dentinal tubules may extend to the pulp;
2. The second is where the crack is more
peripherally directed and may result in
cuspal fracture.
Pressure applied to the crown of a cracked
tooth leads to separation of the tooth
components along the line of the crack. Such
separation in dentine results in the movement
of fluid in the dentinal tubules, stimulating
odontoblasts in the pulp as well as the
stretching and rupturing odontoblastic
processes lying in the tubules, 3 thus
stimulating pulpal nociceptors. Ingress of
saliva along the crack line may further

increase the sensitivity of dentine.13 Direct

stimulation of pulpal tissues occurs if the
crack extends into the pulp.
Classification Types of Crack 2
The location, direction and extent of a
crack have a profound effect on the choice of
treatment. There are five types of longitudinal
tooth fractures, which are:
1. Craze Lines
2. Fractured Cusp
3. Cracked Tooth
4. Split Tooth
5. Vertical Root Fracture
Longitudinal
tooth
fractures

Craze Lines

Fractured
Cusp

Cracked
Tooth

Split
Tooth

Vertical Tooth
Fracture

Craze lines affect only the enamel.

Fractured cusps, cracked teeth and split teeth
begin on the occlusal surface and extend
apically, affecting enamel, dentin, and
possibly, the pulp. Vertical root fractures
begin in the root. All types except craze lines
are found most often in posterior teeth.
Unlike a broken bone, the fracture in a
cracked tooth will never heal.
Major challenge is the lack of knowledge
concerning the type, characterization and
variety of fractures may lead to misunderstanding with incorrect diagnosis and
inappropriate treatment. These five
categories of longitudinal fractures have been
devised to provide global definitions that
researchers and clinicians can use to decrease
this confusion of classification of type of
fracture, especially that related to prognosis
and treatment modalities.
One factor that contributes to the
confusion surrounding the issue of cracked
teeth is that various authors have suggested a
number of inconsistent terms to describe
tooth cracks. For instance, complete and
incomplete have been used to refer to a

Professor & HOD

Dr. Vacha Patel

P.G. Student

Dr. Yesha Jathal

P.G. Student
Dept. of Conservative Dentistry & Endodontics
Faculty of Dental Science, Dharmsinh
Desai University, College Road,
Nadiad (Gujarat)
Address for Correspondence
Dr. Suhani Patel
15, Tirthnagar society Part-2,
Opp. New Nikita Park, Near Sun-n-Step Club,
H.B Kapadia School Road, Memnagar,
Ahmedabad-380052
suhanidec7th@gmail.com

variety of crack features, including degree of

pulpal involvement, degree of root
involvement or extent of the crack.
Classification schemes that only consider
whether a fracture is complete versus
incomplete will not readily illuminate these
differences.
Types of the cracks and fractures
discussed here could be called vertical
fractures. Also, each fracture that involves
the tooth root, whether originating from the
coronal (enamel) or apical (root)2 portion of
the tooth, can be termed vertical root
fractures. Therefore, a crack that extends
from crown to root in a mesiodistal direction,
a split tooth and a true vertical root fracture
that involves only the root, have been termed
vertical root fractures.
Craze Lines2
In posterior teeth, craze lines are usually
evident crossing marginal ridges and
extending along buccal and lingual surfaces
(Fig. 1). Long vertical craze lines commonly
appear on anterior teeth. As they only affect
the enamel, they cause no pain and are of no
concern beyond the aesthetic. On
examination of teeth for cracks, it is observed
that most adult teeth have craze lines.
Fractured Cusp2
The term fractured cusp is defined as a
complete or incomplete fracture initiated
from the crown of the tooth and extending
subgingivally, usually directed both
mesiodistally and buccolingually. The
fracture usually involves at least two aspects
of the cusp by crossing the marginal ridge and
also extending down a buccal or lingual
groove. The fracture will extend to the
cervical third of the crown or root.
Of all cracks affecting dentin, cusp
fractures are the easiest to identify and treat.
Their treatment also has the best prognosis,
especially when the crack does not extend
below the gingival attachment.
The fractured cusp usually results from a

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Endodontics
Patel, et al. : Cracked Tooth Syndrome-Decoding the Enigma

lack of cusp support due to a weakened

marginal ridge. Occlusally, it is common for
the crack to have both a mesiodistal and a
buccolingual component. The crack will
cross the marginal ridge and continue down a
buccal or lingual groove to the cervical
region. It may terminate parallel to the
gingival margin or slightly subgingivally
(Fig. 2). Generally, only one cusp is affected.
It may be necessary to remove a restoration,
stain the tooth and/or transilluminate to locate
the cracks. Magnification may be helpful in
determining the extent.
Cracked Tooth2
As per definitioncracked tooth is as an
incomplete fracture initiated from the crown
and extending subgingivally, usually directed
mesiodistally. The fracture may extend
through either or both of the marginal ridges
and through the proximal surfaces. The
fracture is located in the crown portion of the
tooth only or may extend from the crown to
the proximal root (Fig. 3). Cracked teeth are
described as incomplete (greenstick)
fractures, which also describes their form.
Occlusally, the crack is more centered and
apical than a fractured cusp and, therefore,
more likely to cause pulpal and periapical
pathology as it extends apically (Fig. 3).
Cracked teeth occur most commonly in
mandibular molars, followed by maxillary
premolars. The crack may rarely be
buccolingual in mandibular molars. They do
not occur in anterior teeth and are rare in
mandibular premolars.
Split Tooth2
The term split tooth is defined as a
complete fracture initiated from the crown
and extending subgingivally, usually directed
mesiodistally through both of the marginal
ridges and the proximal surfaces. The fracture
is located coronally and extends from the
crown to the proximal root (Fig. 5). A crack
that is more centered on the occlusion will
tend to extend more apically. A split tooth is
the end result of a cracked tooth; the fracture
is now complete and extends to a surface in all
areas. The root surface involved is in the
middle or apical third, usually extending
toward the lingual. There are no dentin
connections; tooth segments are now entirely
separate (Fig. 5). The split may occur
suddenly, but it more likely results from longterm growth of an incomplete cracked tooth.
Identification of a split tooth is by a
readily apparent or easily disclosed crack
with segments that separate with wedging
forces, such as probing with an explorer or
instrument placed into the occlusal cavity
preparation (Fig. 5).
Patients will usually complain of marked
pain to chewing and significant soreness of
the jaw or gums. Periodontal involvement,
however, may complicate the diagnosis of
CTS and may mislead the clinician towards
periodontal abscess.
Vertical Root Fracture (VRF)2
A true vertical root fracture is defined
as a complete or incomplete fracture initiated

26

from the root at any level, usually directed

buccolingually. The fracture may involve one
proximal surface (buccal or lingual) or both
buccal and lingual proximal surfaces. The
fracture is located in the root portion of the
tooth only, and may extend coronally toward
the cervical periodontal attachment (Fig. 6).
A VRF may extend the length of the root
or occur as a shorter crack at any level along
the root. The crack may or may not extend to
both buccal and lingual surfaces (Fig. 6).
VRF present with minimal signs and
symptoms, and hence, they tend to go
unnoticed until periapical pathologydevelops. But once this happens, these are
very difficult to diagnose because they mimic
other conditions. The recommended
treatment for VRF is extraction or removal of
the cracked root.
Etiology of CTS
Common causes include masticatory
accidents, such as biting on a hard, rigid
object with unusually high force,3,4 or

vulnerable. 8,18,19
Excessive condensation pressures,
expansion of certain poorer quality amalgam
alloys when contaminated with moisture,
placement of retentive pins, and extensive
composite restorations placed without due
care for incremental technique (resulting in
tensile forces in the tooth structure due to
polymerization contraction) predispose to
fracture formation. 3
Other iatrogenic causes of CTS include
excessive hydraulic pressure in luting agents
when cementing crowns or bridge
retainers. 8 , 1 8 Long-span bridges exert
excessive torque on the abutment teeth,
leading to crack generation.3
Symptoms & Diagnosis
Successful diagnosis of CTS requires
awareness of its existence and of the
appropriate diagnostic tests. The history
elicited from the patient can give certain
distinct clues. Pain on biting that ceases after
the pressure has been withdrawn is a classical

Table 1. : The Etiology of Cracked Tooth Syndrome

Classification

Restorative
Procedures

Occlusal

Developmental

Miscellanceous

Factors

Examples

Inadequate
design
features

Over-preparation of cavities
Insufficient cuspal protection in inlay/onlay design
Deep cusp-fossa relationship

Stress
Concentration

Pin Placement
Hydraulic pressure during sealing of tightly fitting cast restorations

Stress
Concentration

Physical forces during placement of restoration, e.g., amalgam or

soft gold inlays (historical)
Non-incremental placement of composite restorations (tensile stress
on cavity walls)
Torque on abutments of long-span bridges

Masticatory
Accident

Sudden and excessive biting force on a piece of bone

Damaging
horizontal
forces

Eccentric contacts and interferences

(especially mandibular second molars)

Functional
Force

Large untreated carious mlesions

Cyclic forces

Parafunction

Bruxism

Incomplete fusion
areas of calcification

Occurrence of cracked tooth syndrome in unrestored teeth

Thermal cycliong

Enamel cracks

Foreign body

Lingual barbell

Dental instruments

Cracking and crazing associated with high-speed handpieces

excessive removal of tooth structure during

cavity preparation.14 Parafunctional habits
such as bruxism are also associated with the
development of this condition.1,14
Commonly, the tooth has been
structurally compromised by removal of
excessive amount of tooth substance during
restorative procedures.14 Occlusal contact
occurring on extensive occlusal or proximoocclusal intra-coronal restorations (either
cast metal or plastic restorations) subject the
remaining weakened tooth structure to lateral
masticatory forces, particularly during
chewing.3,4,11 Such cyclic forces result in the
establishment and propagation of cracks.3,11,17
Deep cuspfossa relationships due to overcarving of restorations, or cast restorations
placed without proper consideration for
cuspal protection, also render the tooth

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sign.1,3 Incidences usually occur while eating,

or where objects such as a pencil or a pipe are
placed between the teeth. The patient may
have difficulty in identifying the affected
tooth (there are no proprioceptive fibres in the
pulp chamber).4 Vitality testing usually gives
a positive response, and the tooth is not
normally tender to percussion in an axial
direction.1,2,4 Significantly, symptoms can be
elicited when pressure is applied to an
individual cusp. This is the principle of the
bite tests.3,4,14
Here the patient is instructed to bite on
various items such as a toothpick, cotton roll,
burlew wheel, wooden stick, or the
commercially available Tooth Slooth
(Professional Results, Inc., Laguna Niguel,
Calif.).2,13,14 Pain increases as the occlusal
force increases, and relief occurs once the

Endodontics
Patel, et al. : Cracked Tooth Syndrome-Decoding the Enigma

pressure is withdrawn (though some patients

may complain of symptoms after the force on
the tooth has been released). The results of
these bite tests are conclusive in forming a
diagnosis.13
The tooth often has an extensive intracoronal restoration.6,15 There may be a history
of courses of extensive dental treatment,
involving repeated occlusal adjustments or
replacement of restorations, which fail to
eliminate the symptoms. The pain may
sometimes occur following certain dental
treatments, such as the cementation of an
inlay, which may be erroneously diagnosed as
interferences or high spots on the new
restoration.16 Heavily restored teeth may also
be tested by application of a sharp probe to the
margins of the restoration.1,16,19 Pain evoked in
this manner can indicate the presence of a
crack in the underlying tooth, which may be
revealed upon removal of the restoration.1,17
Visual inspection of the tooth is useful,
but cracks are not often visible without the aid
of magnifying loupes, specialized techniques
such as transillumination or staining with
dyes such as methylene blue.3,16,17 Areas such
as mesial and distal marginal ridges are more
prone to crack formation.14,17 Occasionally,
cracks are stained by caries or food and are
visible to the unaided eye. Not all stained and
visible crack lines lead to the development of
CTS.
Radiographic examination is usually
inconclusive as cracks tend to run in a
mesiodistal direction.2,11
Treatment of CTS
Immediate treatment of the tooth depends
on the size of the involved portion of the
tooth. If the tooth portion is relatively small
and avoids the pulp (Cameron's peripherally
located crack), it may be fractured off and
the tooth restored in the normal way.2,14 If,
however, the portion is very large or involves
the pulp (Cameron's centrally located
crack), the tooth should be stabilized

immediately with an orthodontic stainless

steel band.2,11 Stabilization, along with
occlusal adjustment, can lead to immediate
relief of symptoms.14 Care should be taken to
prevent microleakage along the crack line, as
this could result in pulpal necrosis.2,8,11 A high
success rate has been reported when fullcoverage acrylic provisional crowns were
used to stabilize the compromised tooth.23
The tooth should be examined after 2 to 4
weeks and if symptoms of irreversible
pulpitis are evident, endodontic treatment
should be performed.2
Ultimately the tooth needs to be restored
with protection and permanent stabilization
in mind.14 This can be achieved with an
adhesive intra-coronal restoration2,4 (e.g.,
bonded amalgam, adhesive composite
restorations) or a cast extra-coronal
restoration (e.g., full-coverage crown, onlay
or three-quarter crown with adequate cuspal
protection) to bind the remaining tooth
components together. 18,19
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.11
Conclusion
The major problem for treatment of
cracked tooth syndrome is the detection and
identification of CTS. Every practitioner
should be aware of the existence of CTS, and
the condition must always be considered
when a patient complains of pain or
discomfort on chewing or biting. A good
history will provide vital assistance in the
search for a diagnosis. Careful clinical
examination and inspection, supplemented
by specialized tests such as the non-axial
application of pressure to cusps, will help in
deriving a proper diagnosis. Treatment of
CTS will depend on the position and extent of
the crack. Management options vary
according to clinical need, from replacement

of the fractured cusp with a simple restoration

to placement of an extra-coronal restoration
with adequate cuspal protection. Armed with
the necessary awareness and conscientiousness, the dental practitioner should have
no significant difficulty diagnosing and
managing the CTS.
References
References are available on request at
editor@healtalkht.com

Legends
Fig. 1.
Fig. 2.

Fig.3(A)

Fig.3(B)

Fig.3(C)

Fig. 4.
Fig.5.(A)
Fig.5.(B)
Fig.5.(C)

Fig.5.(D)

Fig. 6.

Fig. 7.
Fig. 8.

Craze lines, such as those on the occlusal surface

of this tooth, are sometimes mistaken for other
types of cracks.
Occlusal, lingual and distal/proximal views of a
fractured cusp involving the distolingual cusp of
the mandibular right molar. A restoration is
typically present; usually one cusp is involved
and the fracture is not centered as viewed from
the proximal.
Occlusal and distal/proximal views of a cracked
tooth affecting the distal marginal ridge of the
mandibular right molar; the crack has not yet
extended onto the root.
Growth/propagation of the crack to include both
mesial and distal marginal ridges and extending
onto the distal root surface; a restoration is
usually not present and the crack is more
centered as viewed from the proximal.
Further propagation results in a split tooth in
which a separable segment is detected; mesial
and distal marginal ridges are involved and the
fracture extends deeply in the root.
Cracks may be evident across the floor of the
cavity after restoration removal.
Split tooth is visualized and,
Confirmed by using wedging forces, which
resulted in separation of the tooth segment.
The extracted tooth highlights the fracture line
extending from the mesial marginal ridge,
through the floor of the cavity preparation, also
involving the distal marginal ridge.
The proximal view of the extracted tooth shows
a complete fracture that extends deeply to the
root surface with infiltration of granulomatous
tissue.
Facial view of a vertical root fracture, a
horizontal cross-section of a VRF affecting only
the lingual root surface, and a horizontal cross
section of a VRF affecting both the buccal and
the lingual root surfaces; root canal-filling
material is shown in the canal space.
The Tooth Slooth. The concave surface of the
head is placed against the suspect cusp. Using
the Tooth Slooth to identify damaged cusps.
A flowchart for sequential treatment for CTS.

Assessment of Tooth

small peripheral crack

Large central crack

Remove compromised
portion

Fig. 1

Fig. 2

Immediate stabilization
with an orthodontic
band or acrylic crow
+
Occlusal adjustment
if necessary

Immediate stabilization
with an orthodontic
band or acrylic crown
+
Pulpal extirpation

Hopeless prognosis, e.g.

vertical crack, crack
extending through pulpal
floor, poor crown-root
ratio, crack extends below
alveolar bone level

Extract

Fig. 5
Permanent stabilization
and cuspal protection

Bonded restoration, e.g.,

composite, bonded amalgam
(with or without pins)

Fig. 6

Pulpal involvement
detected

Fig. 3

Restore with composite,

pinned amalgam or
appropriate cast
restoration

Fig. 4

No pulpal involvement
detected

Fig. 7

OR

Monitor symptoms and

then complete
endodontic treatment

Cast metal restoration, e.g.,

gold onlay, three-quarter
crown, full gold crown.
Ferrule design indicated if cast
post is required

Fig. 8

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