CRACKED TOOTH

SYNDROME

DEFINITION

An incomplete fracture of a vital posterior tooth that involves the dentine and occasionally extends to the pulp or the periodontal ligament .

INCIDENCE

Age range is b/w 30 and 50 yrs Both sexes are equally affected Commonly affected teeth ----mand 2nd molars followed by lower 1st molars and max premolars Cracks are usually mesiodistally extended In mandibular molars buccolingual extension is seen( anatomical variation)

CLASSIC PATTERNS OF EXTENSION

1ST Cracks are in center and extend towards the pulp 2nd Cracks are peripherally located and extend to the cusps causing cuspal fracture

HOW DOES THE SYNDROME DEVELOPS?

Pressure applied to CT separates tooth components along line of crack Movement of fluids in dental tubules Stretching n tearing of odontoblast processes---------pulp nociceptors are stimulated Dentine sensitivity starts Pulp stimulated if crack reaches the pulp Crack can even reach the furcation area

WHEN A CRACK IN A TOOTH IS NOT A CRACK?

When its a craze. Present in normal dentition Forms with age and usually anteriorly Patient has no symptoms

HISTORY & SYMPTOMS

Sharp erratic pain on biting or withdrawal of biting pressure Sensitivity to hot and cold Identification of the tooth may be difficult History of bruxism History of repeated occlusal adjustments Prolonged pain which could not be diagnosed

HISTORY & SYMPTOMS contd..

Pain

may be intermittent Pain may be of short duration It has progressed to constant toothache

DIAGNOSTIC TOOLS
-

Magnifying loupes Surgical microscopes Transillumination light Staining.methylene blue Cotton rolls Tooth slooth radiographs

CLINICAL TESTS

Visual examination Examination of teeth with a sharp probe(Heavily restored teeth,cracked teeth, presence of facets on occlusal surfaces,caries, mesial & distal marginal ridges) Examine presence of periodontal pocket Transillumination

CLINICAL TESTS contd..

Staining of teeth

Hot or cold tests Biting Tests .Pain on application of a diagnostic tooth Slooth or cotton rolls Radiographs Removal of filling

THE SUSPECTED TOOTH

Can have a very large or no filling at all Vitality test can be positive or negative May or may not be painful when percussed axially Pain elicited when a particular cusp is percussed as recently been filled e.g.. Inlay Has a large carious cavity

Has developmental problems

CAUSES OF CRACKED TOOTH SYNDROME

1. Restorative procedures
------Over-preparation of cavities
Inadequate

design features Insufficient cuspal protection in inlay/onlay design Deep cusp fossa relationship

Restorative procedures contd..

------------ Stress concentration Pin placement Hydraulic pressure during seating of tightly fitting cast restorations 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

2. Occlusal factors
Masticatory

accident Damaging horizontal forces Parafunction Functional forces

3.

Developmental factors

Incomplete

fusion of areas of calcification Occurrence of cracked tooth syndrome in unrestored teeth

4.

Miscellaneous

Foreign

body Dental instruments Thermal cycling

TREATMENT OPTIONS

Assessment of tooth
Small peripheral cracks

Remove compromised portion

Restore with composite ,pinned amalgam restoration, cast restoration

Assessment of tooth
Asse ssme nt of Large central crack tooth No pulpal involvement detected

Immediate stabilization with orthodontic band, acrylic crown + occlusal adjustment if necessary Permanent stabilazation & cuspal protection
Bonded restoration Cast metal restoration

Assessment of tooth
Large central crack Pulpal involvement Immediate stabilization with an ortho band or acrylic crown + pulpal extirpation Monitor symtoms and thn complete endodontic treatment Permanent stabilization and cuspal protection

Bonded restoration

Cast metal restoration

Assessment of tooth
Large central crack

Hopeless prognosis e.g - teeth with vertical crack, -Crack extending through pulpal floor, -poor crown root ratio, -crack extends below alveolar bone level

Extract

PREVENTION

Conservative prep of cavities Rounded internal angles Adequate cuspal protection Cast retorations should be fit in passively Pins should be placed in sound dentine Prophylactic removal of eccentric contacts should be removed in previous CTS cases

SOME PRESENTATIONS OF CRACKED TOOTH SYNDROME

CASE PRESENTATION

Quranic Quote
Then, after them some of the successors who succeeded them lost prayer and pursued lustful desires, so they shall soon come across the out of turpitude (HELL). (Surah Maryam: Ayat 59)