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Malarvili Mugunthan
It is an incomplete fracture of a vital posterior tooth that involves the dentine and occasionally extends into the pulp. The term was introduced by Cameron in 1964. Patients aged between 30 and 50 years are commonly affected.
Mandibular second molars, followed by mandibular first molars and maxillary premolars, are the most commonly affected teeth. Two classic patterns of crack formation exist. *The first occurs when the crack is centrally located and following the dentinal tubules may extends to the pulp.
**The second is where the crack is more peripherally directed and may results in cuspal fracture.
Thermal cycling and parafunctional habits have also been implicated in the development of enamel cracks in such unrestored teeth. Nowadays common causes include
Masticatory accidents such as biting on a hard, rigid object with unusually high force. Excessive removal of tooth structure during cavity prepration. Parfunctional habits - Bruxism.
Excessive condensation pressure, expantion of certain poor quality amalgam alloy when contaminated with moisture,placement of retentive pins predispose to fracture formation. Other iatrogenic causes of CTS include excessive hydraulic pressure in luting agent when cementing crown and bridge retainers.
Ingress of saliva along the crack increase the sensitivity of dentine. Direct stimulation of pulpal tissues occurs if the crack extends into the pulp. Vitality test. usually positive Normally not tender to percussion in an axial direction. Diagnosis should exclude pulpal, periodontal or periapical causes of pain.
Galvanic pain associated with recent placement of amalgam should be ruled out. pain occurs on closing the teeth together but decreases as full contact is made, but in CTS pain increases as the teeth close further together due to increase occlusal forces. Medical history Oro facial pain or psychiatric disorders should also be excluded. Visual inspection. With the aid of magnifying loupes, transillumination and staining with methelene blue.
BITE TEST
Bite on various items. Toothpick, cottonroll orangewoodstick or the commercially available tooth slooth. Tooth slooth small plastic bite block attached to the handle. Pyramidal in shape. At the apex of the pyramid is a small concavity which accomadate the cusps of the tooth
Radiographs. Usually inconclusive as cracks tend to run in a mesio distal direction rather than bucco lingual direction. Bucco - lingual cracks will only appear if the segments are separated or the same angle as the x-ray beam. Periodontal probing. Narrow pocket formation along the crack can be differentiated from the broad-base pocket in periodontal diseases.
Treatment of CTS
The key successful treament of the CTS lies in early diagnosis. If patient presents early and the condition is diagnosed application of a stainless steel band will frequently cease the problem. Review after 2-4 weeks. If no pain diagnosis confirmed.
The ideal permanent restoration for such tooth is a full coverage crown. Pain on biting with pain on temperature changes sedative dressing (IRM) placed to sedate the pulp. If cusp flies off during removal of the fillingreplace the lost tooth substance- overlay, gold and porcelain onla Vertical crack or the crack extends through the pulpal floor or below the level of the alveolar bone prognosis hopeless. Extraction is the treatment.
If sensitivity to temperature changes has not ceased or the crack extends into pulp. endodontic therapy is necessary.
Prevention
Awareness of the existance and etiology of CTS is important. Cavity preparation conservatively. Round internal line angles preferred to sharp line angle to avoid stress concentration. Pin placement in sound dentine at appropriate distance from enamel.
References
Australian Dental Journal. 1990,35(2):10512 Journal of the canadian Dental Association The cracked tooth syndrome. September 2002, vol. 68, no.8 Australian Dental Journal 1998;43:4