E-ISSN 2348-3407

DOI: 10.4103/2348-3407.135075 Review Article

Cracked tooth syndrome

Rajesh Shetty, Arpita Agarwalla, Pritesh Jagtap, Nikita Patel, Ankush Katkade, Shrutika Somani

Department of Conservative Dentistry

and Endodontics, Dr. Dnyandeo
Yashwantrao Patil Dental College and
Hospital, Pimpri, Pune, Maharashtra,
India
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Abstract
Cracked tooth syndrome (CTS) is both a transient and progressive condition. There are numerous factors that
may predispose a tooth to varying degrees of a crack. Incompletely fractured teeth are capable of causing great
discomfort to the patient and it is also a source of concern for the dental practitioner. Diagnosis of CTS can be
difficult. The patient reports with pain, and often the dentist relies on a periapical radiograph to determine
the origin of the pain. Because CTS is a vital pulp condition, the periapical radiograph is of limited value as a
diagnostic test. As a result, lack of treatment, or inappropriate treatment, will not resolve the symptoms, and
the condition can result in the eventual loss of the affected tooth. This article will present the epidemiology,
classification, etiology, signs and symptoms, the accurate diagnosis modalities and treatment options, along
with prognosis and future prospects for this clinical condition through the undertaking of a comprehensive
literature review of contemporarily available data.

Key words: Crack, craze lines, fracture, vertical root fracture

Introduction Through a comprehensive literature review, this article aims

Cameron coined the term cracked tooth syndrome (CTS)
to define the condition as “an incomplete fracture of a vital
posterior tooth that involves the dentin and occasionally
extends to the pulp.”[1,2]
In recent times, the definition has been modified as follows:
“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.”[3]
The incidence of cracks in teeth seems to have increased since
the last three decades. This is probably because of better health
care facilities, people live longer and their teeth last longer
too, thus making them more susceptible to cracking, from
normal wear and tear. Stress and stress‑related habits such
as bruxism and clenching have also become more prevalent,
thereby contributing to the increased incidence of cracks.
Finally, because dentists are becoming increasingly aware of
the existence of cracks, more cracks are being diagnosed than
before.[4]
Other terms often used interchangeably with CTS include:
“incomplete fracture of posterior teeth”. [5] “green-stick
fracture”, “split tooth syndrome.”[6]
to provide an overview of the epidemiology, classification,
etiology, signs and symptoms, diagnosis, treatment and
prognosis, as well as future prospects of cracked teeth which
may be a diagnostic challenge in clinical practice.
Materials and Methods
Search criteria
Inclusion criteria
• The search was limited to review articles and case
studies involving human subjects
• Restrictions were not placed regarding the study design
and the language usage
• A minimum follow‑up duration of 1 year was selected
• All original research articles, review articles, case
reports, case series, and pilot studies were included.
Exclusion criteria
• Publications that did not meet the above inclusion
criteria are excluded
• Studies conducted on animals.
Search strategy
A literature review was performed in Pubmed Central,
MEDLINE, the Cochrane Library, and the EBSCO host. The
articles identified included those published up to November,

Correspondence to: Dr. Arpita Agarwalla, PG Student in Department of Conservative Dentistry and Endodontics, Dr. Dnyandeo Yashwantrao
Patil Dental College and Hospital, Pimpri, Pune - 411 018, Maharashtra, India. E-mail: arpita.agarwal19@gmail.com

Journal of Dental Research and Scientific Development | 2014 | Vol 1 | Issue 2 51

 Shetty, et al.: Cracked teeth
2013 with the following Medical Subject Headings  (MeSH)
terms and/or key words in various combinations: Cracked
tooth, vertical root fracture, tooth fracture, split tooth, cuspal
fracture odontalgia, bite tests, and splinting. About 272 articles
were found, out of which many were excluded based on the
exclusion criteria mentioned above and 60 of the articles were
used for this review.
Discussion
Epidemiology
The presence of a cracked tooth occurs primarily in adulthood.
Contradictory data were reported regarding the correlation
between a patient’s age and the occurrence of CTS.
Fitzpatriek[7] observed that incomplete fractures primarily
occurred in people between the ages of 30-39; these findings
indicate that more and more young patients are affected
by CTS.[8] Luebke[9] found mandibular olars especially the
distolingual cusp to be the most susceptible to cracking. The
maxillary molars and premolars have a similar incidence
of fracture, with the mandibular premolars being the least
susceptible because the stresses during mastication is minimal
on these teeth.[10] Cracks not only appear in restored teeth but
also may occur in intact ones.
Classification of tooth fractures-(By American Association
of Endodontics)[11]
They can be classified into five broad categories-each differing
in location and severity. In order of increasing severity, the
categories are: (1) Craze line, (2) fractured cusp, (3) cracked
tooth, (4) split tooth, and (5) vertical root fracture.[11]
• Craze lines: They involve enamel only and are usually
asymptomatic. In posterior teeth, craze lines are usually
evident crossing marginal ridges and/or extending
along buccal and lingual surfaces. Long vertical craze
lines are often found in anterior teeth[12]
• Fractured cusp: According to the American Association
of Endodontists, the fractured cusp results from a lack
of cusp support due to a weakened marginal ridge. It is
the easiest to identify and treat with the best prognosis
• Cracked tooth: The depth of this crack is variable, it
occurs in a mesiodistal direction. The most challenging
form of incomplete tooth fracture is a cracked tooth,
which may be difficult to diagnose and is a source of
frustration for both the dentist and the patient
• Split tooth: A split tooth extends from one proximal surface
to the other; fracture is complete and extends across the
tooth.[1] A split tooth can never be saved intact, and the
position as well as extent of the crack will determine
whether any portion of the tooth can be salvaged; in most
cases, the whole tooth must be extracted[4]
• Vertical root fracture‑Vertical root fractures are cracks
that begin in the root of the tooth and extend occlusally.
Journal of Dental Research and Scientific Development | 2014 | Vol 1 | Issue 2
The diagnosis can be difficult to establish because the
fracture can mimic other conditions such as sinusitis,
atypical facial pain, etc., Treatment is usually extraction
of the tooth.[13]
Etiology
The etiology of CTS is multifactorial. Guersten et al.,[14] stated
that “excessive forces applied to a healthy tooth or physiologic
forces applied to a weakened tooth can cause an incomplete
fracture of enamel or dentine.”
Lynch et al.,[15] have subdivided the causes of cracks into four
major categories: Restorative procedures, occlusal factors,
developmental conditions, and miscellaneous factors.
Restorative procedures
• Pin‑retained restorations  (self‑threaded or friction lock
pins)[16]
• Tightly fitting cast restorations[6] (excessive hydraulic
pressure while luting)
• Non‑incremental placement of composite restorations.
• Torque on abutment in long span bridges
• Excessive removal of tooth tissue during cavity
preparation which significantly lowers tooth
rigidity.[17] A cavity of width more than one‑fourth of the
intercuspal distance is at an increased risk of fracture[18]
• Ratcliff et al.,[19] found that a tooth with an intra‑coronal
restoration is at a risk of fracture 29  times greater
than that of an unrestored tooth. Differences in the
coefficients of thermal expansion between that of the
tooth tissue and restorative material may also have the
potential to induce fracture.[20]
Even endodontically treated teeth are at an increased risk of
fracture, the reason being the loss of hard tooth substance
during preparation of the access cavity.[19]
Sometimes due to high forces applied during lateral compaction
of gutta percha or cementation of a post, vertical cracks may
appear.[21]
It has been found that 26-72% of endodonticaily treated
posterior teeth restored with mesio‑occlusal, disto‑occlusal,
or mesio‑occlusodistal amalgam restorations cracked over a
20‑year period.[22]
• Occlusal factors: It has been stated that CTS most
commonly occurs because of using excessive force to
bite suddenly on a hard object.[6] Fracture may also
be caused by trauma from occlusion. A great amount
of force is applied during parafunctional habits such
as nocturnal bruxism, the reason for this being the
suppression of cortical inhibitors during sleep[23]
• Developmental conditions: Various morphologic
factors maybe the possible cause for cracked teeth, like
deep occlusal grooves, pronounced vertical radicular
52
 Shetty, et al.: Cracked teeth
grooves, or a bifurcation. Thus, maxillary premolars
are significantly more susceptible to fracture than
mandibular premolars. Additionally, an extensive pulp
space, a “steep cusp/deep groove” inter‑relationship
between the maxillary and mandibular premolars,
and the resulting wedging effect of the prominent
facial cusps of mandibular premolars, contribute to
the increased susceptibility to fracture of maxillary
premolars.[24,25]
• Miscellaneous factors‑Miscellaneous factors include
wasting diseases like abrasion, erosion or attrition.
acidogenic extensive loss of enamel and dentin,
andbulimia or anorexia nervosa, may also increase the
risk of a fracture.[14]
In recent years, the lingual barbell or tongue piercing has been
identified as a frequent cause for cracks on teeth.[26]
With age, dental tissues become more brittle and less elastic,
thus even forces which were otherwise within normal
physiologic limits may exceed the elastic limits of an aged
dentition, making it more susceptible to fracture.[27]
Signs and symptoms
The most classic symptom of CTS is a history of sharp pain when
biting or while consumption of hot/cold beverages.[28] This pain on
biting increases as the applied occlusal force is raised.[27] The pain
usually occurs on release of pressure when fibrous foods are eaten,
hence it is known as “rebound pain.”[12] The alternative stretching
and compressing of the odontoblastic processes located in the
crack has been thought to be the cause for this short, sharp pain.[24]
This pain has also been accounted to the sudden movement
of fluid present in dentinal tubules which occurs when the
fractured portions of the tooth move independently of one
another, which results in the activation of myelinated A‑type
fibers within the dental pulp. Hypersensitivity to cold may
also occur as a result of the seepage of noxious irritants
through the crack, which results in the subsequent release of
neuropeptides causing a concomitant lowering in the pain
threshold of unmyelinated C‑type fibres within the dental
pulp.[29]
Very often fractures are not diagnosed in time because of
which they may enter the pulp chamber, causing pulpal
inflammation and necrosis. Fractures extending to the root
generally cause periodontal inflammation. Thus, a localized
periodontal breakdown adjacent to a restored tooth frequently
indicates a fracture.[5]
Diagnosis
Diagnosing CTS has proved to be difficult even for the
most experienced dental practitioners, the reason being that
associated symptoms are usually very variable and sometimes
even bizarre.[30]
Journal of Dental Research and Scientific Development | 2014 | Vol 1 | Issue 2
Successful treatment and favorable prognosis would depend
on an accurate and early diagnosis.
A detailed history is imperative along with a thorough
assessment of all symptoms, though these vary with the depth
and orientation of the crack.
If the crack is directly visible, diagnosis can be fairly simple.[5]
This is possible in cases where there is exogenic staining from
food or beverages. But more often than not, common mesiodistal
cracks are not visible because most of these teeth present with an
overlying occlusal or proximal restoration. Hence removal of these
restorations may prove to be useful.[28] With larger restorations,
cracks tend to be more superficial and thereby produce fewer
symptoms, whereas with smaller restorations cracks tend to be
deeper and closer to the pulp.[31] Initial cracks may not be visible
because they are too small to be detected by the naked eye.[32]
Many authors have suggested the use of stains like gentian
violet or methylene blue to stain the fracture line and make it
visible.[30] But this technique still has its disadvantages-first,
that staining may take many days to become effective,
hence requiring an interim restoration[5] which may further
compromise the structural integrity of the tooth. Furthermore,
after the use of these dyes, placing a definitive aesthetic
restoration may prove to be difficult.[28]
Magnifying loupes and transillumination using a fiber‑optic
device have been considered instrumental in the diagnosis of
a cracked tooth.[16]
One of the classic symptoms of CTS, which most dental
operators consider to be an important indicator, is cold
sensitivity and sharp pain on biting hard or tough food which
ceases on the release of pressure.
This “relief pain” can be replicated by bite tests.[15] To
accurately diagnose an incomplete fracture by the use of any
of the following-orange wood sticks, cotton-wool rolls, rubber
abrasive wheels such as a Burlew wheel or the head of a number
10 round bur in a handle of a cellophane tape.
In order to localize the cusp affected by CTS, a wood stick can
be rested on each individual cusp of the suspected tooth and
the patient asked to bite. According to Kruger, pain produced
by release of pressure confirms a case of CTS.[33]
The use of commercially available diagnostic tools like
Fractfinder (Denbur, Oak Brook, IL, USA) and Tooth Slooth
II  (Professional Results Inc., Laguna Niguel, California,
USA) have found to be more sensitive and accurate in the
identification of the affected/involved cusp when compared
with the more conventional tools.[1]
Most cracks propagate in a mesiodistal direction, because of
which radiographs are barely of any use.[15] However in the
53
 Shetty, et al.: Cracked teeth
rare cases where the fracture occurs bucco‑lingually they are
valuable in the diagnosis.[34]
But Cone Bean Computed Tomography (CBCT) may prove to
be useful in many cases.
Treatment
Immediate therapy
To avoid irreversible damage, it is imperative that a cracked
tooth be treated as soon as possible.
Occlusal adjustment of affected teeth must be done immediately
to reduce the stress on the tooth and prevent further damage
to the tooth.
If the tooth in question presented with a preexisting restoration, it
should be removed. This may cause the affected cusp to “splinter
off” and the further treatment protocol can then be decided.[35]
In case there is no splintering, immediate immobilization
should be employed, using an “immediate extra‑coronal
circumferential splint.” A copper ring or a stainless steel
orthodontic band can be used for this purpose.[5]
The use of full coverage acrylic provisional crowns has been
advocated for “immediate splinting.”[36]
Another available option is the use of bonded composite resin
to splint the teeth, which is known as a “direct composite
splint” (DCS).[37]
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Definitive therapy
In case of non splintering teeth, intra coronal restorations,
without cuspal coverage may also be used. Dental amalgam,
composite resin and glass‑ionomer cements are most commonly
used. The strength of the tooth can be restored by using these
materials.[38]
Amalgam overlays have been found to increase the fracture
energies of cracked teeth to levels equivalent to that of intact
teeth.[39] Hence direct restorations with cuspal coverage have
been advocated as a primary mode of treatment.[31]
In cases where aesthetics is not a matter of great concern,
cast metal inlays with cusp coverage or partial crowns with
circumferential external splinting are applied or else, adhesive
ceramic restorations can also be used.
Full coverage crowns are the most appropriate form of
restoration for cases where the crack extends from the occlusal
incline to the cervical third of the clinical crown.[36]
It has been reported by a number of authors that the loss of
vitality following the application of full coverage single unit
crowns is in the range of 15-19%. Loss of pulpal vitality is an
obvious problem following the preparation of teeth to receive a
full coverage crown. In CTS, reversible pulpitis would already
be a pre‑ existing condition so the problem appears to be further
compounded [Figure 1].[15,40,41]
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Figure 1: Treatment options

Journal of Dental Research and Scientific Development | 2014 | Vol 1 | Issue 2 54

 Shetty, et al.: Cracked teeth
Prognosis
In case of a cracked tooth, the patient should be fully informed
that the prognosis is questionable at best. A number of factors
would need to be considered before evaluating the prognosis
of a cracked tooth.
The location and extent of the crack is probably the most
important of these factors.[42] Prognosis is considered excellent
for cracks that are limited to dentine and not involving the
dental pulp, or for those fractures which are limited to a
single marginal ridge which do not extend more than 2‑3 mm
below the periodontal attachment.[43] The prognosis becomes
poor in cases involving both marginal ridges, or reaching up
to the pulp.[44] Prognosis is defined to be hopeless in cases
which present with complete mesio‑distal fractures, or where
gingivoplasty or an alveoplasty does not expose the fractured
segment.[43]
Anatomy of the tooth and roots, the previous operative/
restorative history of the tooth and the functional forces acting on
the tooth (during both functional and parafunctional activity), are
other factors affecting the prognosis.[15] The loss of pulp vitality
has also been found to have adverse effects on the prognosis of
the tooth.[44] Finally the technique used and skill and experience of
the operator can also affect the long term prognosis of such teeth.
Future prospects
In recent years the ability of Swept Source Optical Coherence
Tomography (SS‑OCT) to detect cracks has been evaluated and
it has been found that, it can clearly discriminate cracks, which
appear as highlighted lines due to the scattering of light.[45] But
further clinical studies would be required before this technique
could be used extensively.
The DCS has also been found to have the potential, in theory,
to be used as both an immediate and intermediate restorative
option. It is a biologically conservative, aesthetic, easy to
apply and inexpensive treatment modality.[37] But before this
treatment option can be applied in every‑day dental practice,
considerable further clinical research is needed.
Conclusion
The CTS presents both a challenge and an opportunity for the
dentist. The diagnosis of this condition can be difficult, but every
attempt must be made to do it with expediency. Though a number
of definitive restorative techniques have been described for the
treatment of posterior teeth affected by CTS, there is very limited
clinical evidence available in the dental literature to substantiate
the use of any of them. Three principal factors determine the
prognosis of a tooth affected by CTS: The extent and location of
the fracture, the point in time when restorative intervention is
initiated and thirdly by the type of restoration applied to splint
the fracture. It is our foremost duty to provide a solution to
the problem the patient comes to us with. No matter what the
Journal of Dental Research and Scientific Development | 2014 | Vol 1 | Issue 2
prognosis of the particular tooth, all available treatment options
must be known to the dentist and explained well to the patient
to help him decide on and initiate the proper treatment plan.
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How to cite this article: Shetty R, Agarwalla A, Jagtap P, Patel N,
Katkade A, Somani S. Cracked tooth syndrome. J Dent Res Sci Develop
2014;1:51-6.
Source of Support: Nil Conflict of Interest: No conflict of interest.

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