Research Decision Analysis on the Management of Cracked Tooth

Kavalipurapu Venkata Teja and Sindhu Ramesh* Department of Conservative and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India Abstract Corresponding author: Sindhu Ramesh, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Background: Tooth fractures are commonly encountered in day to day Hospitals, Saveetha Institute of Medical and dental practice. The consequences of these fractures can range from a minor Technical Sciences, Saveetha University, Chennai, India, E-mail: to severe from a stage where no treatment is needed to a stage leading to [email protected] root canal therapy or even tooth loss. One form of these fractures include . It often presents a difficulty in diagnosis to the dentist and many times it’s a painful and a frustrating event to the patient. Cracked tooth syndrome is a term applied to a presumptive diagnosis of an incomplete tooth fracture which typically presents with the symptoms of pain on biting and responds to temperatures especially to cold stimuli. Routine clinical examinations in patients with asymptomatic teeth, often uncover these fracture lines. Unfortunately, by the time these incomplete tooth fractures become symptomatic, tooth may already be destined to root canal therapy or extraction. Hence appropriate knowledge is needed for dentists in the prevention, diagnosis and treatment of the cracked teeth. Aim: To provide decision analysis tree for the management of cracked tooth. Methodology & Results: Literature search was carried out on cracked teeth and a decision tree analysis was framed for the management of cracked teeth.

Keywords: Cracked teeth; Root canal therapy; Extraction; ; Trans-illumination

Introduction stress planes causes the complete fracture of the teeth resulting in the separation of the tooth piece along the stress plane. A cracked tooth is a condition that occurs in a tooth where Sometimes a single sudden traumatic hit results a complete there exists a partial or a complete fracture along the stress fracture along these stress planes. [4] plane that commonly occurs in that tooth. [1] The endodontic and periodontal prognosis of the fractured A tooth stress plane is resulted from the occlusal force that teeth depend on what aspects of the tooth are intersected by is commonly imposed on a tooth during mastication. So that, the existing fracture or would be intersected if the tress plane any instance of higher energy is always concentrated along is fractured completely. A tooth fracture plane or a stress these stress planes. plane, may be completely supra or sub-gingival and may or may not intersect with the pulp chamber, a furcation or a These higher energies result in the disruption of some chemical sub-gingival aspect of the root surface or a tooth root, making bonds within the natural tooth while travelling along the stress the prognosis poor. [5] planes. Types of Furcation Fractures A clinically significant fracture, may develop on long run of several masticatory loads along these stress planes. [2] As the Various types of furcation fractures, cuspal fractures, root fracture proportionately expands, due to proportionate fractures, craze lines, gingival interface fractures may be stress being put on the remaining un-fractured area of the stress defined on what structures the fracture planes intersect. A plane, the rate of fracture theoretically accelerates. partial fracture is considered as catastrophic, if the complete fracture of these stress planes would result to non- restorability Occlusal forces now become capable of causing tooth to flex. This is an open access article distributed under the terms of the Creative Commons If these stress planes are in continuous with the periodontal Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and ligament or pulp chamber they lead to the fluid movement the new creations are licensed under the identical terms. [3] within the odontogenic process, leading to sensitivity. How to cite this article: Teja, RameshDecision Analysis on the Management of Eventually these Cracked ToothAnn Med Health Sci Res.2021;11:100-103 100 ©2021Annals of Medical and Health Sciences Research Teja, Ramesh:Decision Analysis on the Management of Cracked Tooth of tooth with a crown or an endodontic procedure or a post Classification of Tooth Fractures by Talim endodontic restoration. A partial fracture is considered as non- and Gohil catastrophic, when this complete fracture of the stress plane is still restorable with a crown or post endodontic restoration. Class I. Fracture involving enamel Various terminologies have been proposed to describe these • Horizontal or oblique cracked tooth, but there is no clear cut universal agreement • Vertical among the dentists concerning the exact correct descriptive systems. [6] The major reason for this being the inconsistency • Complete in symptoms and the random shapes of these fracture lines that • Incomplete appear clinically. Cameron claimed the phenomena of these cracked tooth be defined as a cracked tooth syndrome. [7,8] Class II. Fracture involving enamel and dentin without Cracked tooth is not a disease. But instead it’s a factor that can involving pulp facilitate the biomechanical, pulpal and periodontal problems. • Horizontal or oblique [9] [10-14] The symptoms of these cracked teeth are inconsistent. • Vertical These two realities contradict the scientific rationale for cracked teeth as a syndrome. Some authors define cracked • Complete tooth syndrome as an incomplete fracture involving the dentin • Incomplete and occasionally extends into the pulp but this definition Class III. Fracture of enamel and dentin involving the pulp excludes the complete fractures of the teeth and also the fractures of the non-vital teeth and doesn’t specify the • Horizontal symptoms of a cracked teeth making the term syndrome • Vertical irrelevant. Some authors claim these fractures as horizontal, • Complete oblique or vertical. [15,16] However, it is very unambiguous to differentiate between different crack types, based on the • Incomplete directions of these fracture planes because these fracture planes Class IV. Fracture of the roots are mostly irregular. Some authors claim that fracture that involves only the enamel is called as a non-structural craze, • Vertical or oblique which doesn’t require any treatment. [17,18] If the structural • Involving the pulp crack in the dentin, become a complete would result in a chunk • Not involving the pulp of the tooth structure fracturing off the tooth. Since outcomes • Horizontal for the teeth with incomplete fractures can be so consequential results a significant problem to both dentists and patients. The • Cervical third stress planes resulting in the incomplete or complete cracked • Middle third tooth are mainly the furcation stress planes, cuspal stress • Apical third planes, gingival interface stress planes and root fractures. Furcation stress planes are such that when a complete fracture These cracked tooth are mostly associated with the intracoronal [19,20] of the stress planes occurs, results in a separation or restorations and most prevalent in mandibular molars. disconnection of one root from another. Complete The highest prevalence rates are seen in patients over 40 years [21] disconnection of a root occurs when these stress planes fracture of age. Some studies state women are being more affected [21] the tooth structure inferior to the pulp chamber floor, which than men, but some others say almost equal in distribution. helps to connect the two roots. Observation of a furcation The best way to prevent these cracks is to understand the fracture in an asymptomatic tooth is possibly an indication that factors that predispose a tooth to crack. The main predisposing tooth is necrotic. Cuspal stress planes occur approximately factors for the cracks are natural and iatrogenic causes. Natural apical to one cusp or apical to two or more connected cusps. include lingual inclination of the lingual cusps of the These stress planes may intersect with the pulp chamber wall mandibular molars, steep fossa or cusp of maxillary , or roof but not the floor. The lateral aspect of these stress , clenching, extensive and abrasion. The planes may intersect with the external buccal or lingual tooth iatrogenic causes include the usage of rotary instruments, [22] surface and possibly a root that is located subgingivally. cavity preparation, and width and depth of the cavity. Age Gingival interface stress plane occurs along the cross section of is also a contributing factor. It has been shown that as the age the tooth structure that is located approximately at the interface of the tooth increases, fatigue resistance of a human dentin [23] between the supra and subgingival tooth structure. Root decreases as a consequence of dehydration. fracture is a fracture of stress plane, contained within a single root, such that complete fracture of the stress plane results in Diagnosis Observations the disconnection of one root from the other. Previously our Cracked tooth syndrome is described in literature as a difficult team has a rich experience in working on various research diagnostic and treatment problem. The diagnosis is purely projects across multiple disciplines. symptomatic with localised pain on chewing or biting with unexplained sensitivity to cold and pain during release of pressure. [24] Several other tests are also performed by a

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clinician to diagnose a cracked tooth syndrome. The most effective assessment of treatment plan, prevention and commonly used ones being the vision enhancers, symptom management of these cracked teeth done successfully and reproducers and radiographs. [25] Fiber optic transillumination maintain the periodontal and biomechanical stability of the and use of light magnification aids like optic loupes or surgical tooth in function. microscope, will aid in the visualisation of crack. [25-27] The tooth should be clean on diagnosing and the light source is REFERENCES being placed directly on the restoration. The crack that penetrates into the dentin will cause the disruption of light 1. Ellis SG. Incomplete tooth fracture- proposal for a new definition. Br Dent J. 2001;190(8):424–8. transmission. Some others state that removal of the restorations Mamoun JS, Napoletano D. Cracked tooth diagnosis and and staining the tooth, [28] will further aid in visualisation of 2. treatment: An alternative paradigm. Eur J Dent. 2015;9(2):293– the crack. The patient's symptoms can be reproduced by 303. percussion, biting and thermal tests. To perform a bite test, a 3. Rosen H. Cracked tooth syndrome. J Prosthet Dent. 1982;47(1): burlew wheel, a small rubber disc or a plastic stick is placed 36–43. over each of the occlusal cusp pain is asked to bite on the tooth 4. Majorana A, Pasini S, Bardellini E, Keller E. Clinical and slot and observed for the pain on the release of pressure which epidemiological study of traumatic root fractures. Dent Traumatol is indicative of a cracked tooth. Radiographs can evaluate the Off Publ Int Assoc Dent Traumatol. 2002;18(2):77–80. pulpal and periodontal helath but they can rarely diagnose a 5. De Bruyne MAA, De Moor RJG. Influence of cracks on leakage crack. Ultrasound can be used as device in diagnosing cracked and obturation efficiency of root-end filling materials after teeth and it can be an important diagnostic aid in future. ultrasonic preparation: an in vitro evaluation. Quintessence Int Although all these diagnostic tests have been reported in Berl Ger 1985. 2008;39(8):685–92. literature, none have been tested on the patient in controlled 6. Kahler W. The cracked tooth conundrum: terminology, clinical trials. Thus still cracked tooth syndrome remains a classification, diagnosis, and management. Am J Dent. difficult condition to diagnose and a source of frustration to 2008;21(5):275–82. both dentist and patient. 7. Cameron CE. The cracked tooth syndrome: additional findings. J Am Dent Assoc 1939. 1976;93(5):971–5. 8. Cameron CE. Cracked-tooth syndrome. J Am Dent Assoc 1939. Treatment 1964;68:405–11. Conventional treatment approaches reported in the literature 9. Kalyan Chakravarthy PV, Telang LA, Nerali J, Telang A. Cracked include some form of the protective cuspal coverage tooth: a report of two cases and role of cone beam computed restorations. The specified protocol is suggested in the tomography in diagnosis. Case Rep Dent. 2012;525364. treatment of cracked teeth. Remove any of the existing 10. Türp JC, Gobetti JP. The cracked tooth syndrome: an elusive diagnosis. J Am Dent Assoc 1939. 1996;127(10):1502–7. restoration, evaluate the health of the pulp and remaining coronal tooth structure and restore with a full crown if 11. Lynch CD, McConnell RJ. The cracked tooth syndrome. J Can Dent Assoc. 2002;68(8):470–5. indicated. Any tooth with irreversible pulpitis or pulpal 12. Lubisich EB, Hilton TJ, Ferracane J, Northwest Precedent. necrosis, RCT has to be performed prior to the crown Cracked teeth: a review of the literature. J Esthet Restor Dent Off placement. Cast gold partial or complete coverage or porcelain Publ Am Acad Esthet Dent Al. 2010;22(3):158–67. fused to metal full coverage and all porcelain can be used. 13. Nguyen V, Palmer G. A review of the diagnosis and management Some authors suggest the removal of the restoration, placement of the cracked tooth. SADJ J South Afr Dent Assoc Tydskr Van of sedative filling orthodontic band stabilization for few weeks Suid-Afr Tandheelkd Ver. 2010 Oct;65(9):396–8, 400–3. and once the symptoms resolve, a restorative build up or a full 14. Banerji S, Mehta SB, Millar BJ. Cracked tooth syndrome. Part 1: coverage restoration can be placed. [29] Some advocate occlusal aetiology and diagnosis. Br Dent J. 2010;208(10):459–63. adjustments in addition to a full coverage restoration. [30] The 15. Schetritt A, Steffensen B. Diagnosis and management of vertical teeth can also be restored with the composite or amalgam root fractures. J Can Dent Assoc. 1995;61(7):607–13. restorations with mechanical retention. [31] Extraction is the 16. Wright EF, Bartoloni JA. Diagnosing, managing, and preventing treatment option where the crack is deep into the bone which is cracked tooth syndrome. Gen Dent. 2012;60(5):e302-307. complete and involves the furcation leading to the pieces to be 17. Johnson R. Descriptive classification of traumatic injuries to the mobile. [32] teeth and supporting structures. J Am Dent Assoc 1939. 1981;102(2):195–7. Conclusion 18. Talim ST, Gohil KS. Management of coronal fractures of permanent posterior teeth. J Prosthet Dent. 1974;31(2):172–8. The periodontal and biomechanical prognosis of the cracked 19. Eakle WS, Maxwell EH, Braly BV. Fractures of posterior teeth in tooth depends on what aspects of the tooth structures are adults. J Am Dent Assoc 1939. 1986;112(2):215–8. involved or intersected by a partial or a complete fracture. It is 20. Gher ME, Dunlap RM, Anderson MH, Kuhl LV. Clinical survey in the hands of the dentist to decide a situation of these of fractured teeth. J Am Dent Assoc 1939. 1987;114(2):174–7. expanding cracks and to go ahead with an appropriate 21. Roh B-D, Lee Y-E. Analysis of 154 cases of teeth with cracks. treatment plan specifically to the patient's condition and needs Dent Traumatol Off Publ Int Assoc Dent Traumatol. 2006;22(3): and provide a hermatic sealing of cracked teeth which is an 118–23. important feature for the long term prognosis. So, it is hoped that in near feature correlation of these diagnostic aids with an

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22. Geurtsen W, García-Godoy F. Bonded restorations for the 28. Jain MR, S G. Dentin comparison in primary and permanent prevention and treatment of the cracked tooth syndrome. Am J molars under compound light microscopy: A study. Res J Pharm Dent. 1999;12(6):266–70. Technol. 2015;8(10):1369–73. 23. Bajaj D, Sundaram N, Nazari A, Arola D. Age, dehydration and 29. Geurtsen W, Schwarze T, Günay H. Diagnosis, therapy, and fatigue crack growth in dentin. Biomaterials. 2006;27(11):2507– prevention of the cracked tooth syndrome. Quintessence Int Berl 17. Ger 1985. 2003;34(6):409–17. 24. Ratcliff S, Becker IM, Quinn L. Type and incidence of cracks in 30. Agar JR, Weller RN. Occlusal adjustment for initial treatment and posterior teeth. J Prosthet Dent. 2001;86(2):168–72. prevention of the cracked tooth syndrome. J Prosthet Dent. 25. Ailor JE. Managing incomplete tooth fractures. J Am Dent Assoc 1988;60(2):145–7. 1939. 2000;131(8):1168–74. 31. Opdam NJM, Roeters JJM, Loomans BAC, Bronkhorst EM. 26. Luebke RG. Vertical crown-root fractures in posterior teeth. Dent Seven-year clinical evaluation of painful cracked teeth restored Clin North Am. 1984;28(4):883–94. with a direct composite restoration. J Endod. 2008;34(7):808–11. 27. Wright HM, Loushine RJ, Weller RN, Kimbrough WF, Waller J, 32. Chong BS. Bilateral cracked teeth: A case report. Int Endod J. Pashley DH. Identification of resected root-end dentinal cracks: a 1989;22(4):193–6. comparative study of transillumination and dyes. J Endod. 2004;30(10):712–5.

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