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Rehabilitation of a Cracked Tooth: A Case Report

Dr. Kshema Mathew ¹*^, Dr. H Murali Rao ², Dr. B S Keshava Prasad ³

¹ Post Graduate Student, Department of Conservative Dentistry and Endodontics, D A Pandu Memorial R V Dental College, J. P. Nagar, Bengaluru, Karnataka 560078

² Professor, Department of Conservative Dentistry and Endodontics, D A Pandu Memorial R V Dental College, J. P. Nagar, Bengaluru, Karnataka 560078

³ Professor and Head, Department of Conservative Dentistry and Endodontics, D A Pandu Memorial R V Dental College, J. P. Nagar, Bengaluru, Karnataka 560078

 

INTRODUCTION

 

Cracked Tooth Syndrome is a clinical diagnostic dilemma that typically manifests as phantom pain. However, the phrase cracked tooth syndrome is frequently deceptive because cracked teeth exhibit a variety of symptoms, and its unpredictability makes it a difficult diagnostic and therapeutic entity. 

A cracked tooth is a tooth in which there exists a partial or complete fracture of a stress plane that commonly occurs in that tooth. Cracked tooth syndrome may be defined as a fracture plane of unknown depth, which originates from the crown, passes through the tooth structure and may extend subgingivally and progress to connect with the pulp space and/or periodontal ligament. The fracture may extend through either or both of the marginal ridges and the proximal surfaces. It may be located in the crown portion of the tooth only or extend from the crown to the proximal root surface. The location, direction, and extent of a crack have a profound effect on the choice of treatment.¹ As an occlusal crack is more centered and apical than a fractured cusp, it is more likely to cause pulpal and periapical pathosis.²

The occurrence of CTS is unknown, but an incidence from 34–74% has been documented.³ In 2006, Roh and Lee reported that cracks were found more frequently in maxillary molars (57.2%) than in mandibular molars (36.3%).⁴Several authors have proposed classifications which are generally based on either the type or location of the crack, the direction and extent of the crack, and / or the risk of symptoms and /or pathological processes. The American Association of Endodontists¹ in a document titled “Cracking the Cracked Tooth Code” identified five types of cracks in teeth which are described in Table 1.

 

 

Table 1: 5 types of crack in a tooth according to AAE

CLASSIFIACTION	ORIGIN	SYMPTOMS	PULP STATUS	PROGNOSIS
Craze lines	Crown	None	Vital	Excellent
Fractured cusp	Crown	Mild pain on biting or cold	Usually vital	Good
Cracked Tooth	Crown and root	Acute pain on biting or cold	Variable	Questionable
Split tooth	Crown and root	Marked pain on biting or cold	Often root filled	Poor
Vertical root fracture	Root	Often shows no symptom	Mainly root filled	Poor

 

 

Signs and Symptoms

The signs and symptoms associated with CTS are: 

1. Acute pain on mastication (pressure or release) of grainy, tough foods and sharp, brief pain with cold.

2. Vary according to position and extend of incomplete fracture. 

3. Pain associated with release of pressure called rebound pain is a consistent finding. 

4. Sensitivity to sweets is seen occasionally. 

5. Pulpal and periodontal symptoms occur when fracture extends to involve pulp.

6. May not be tender to percussion. 

7. Radiographs may be inconclusive.

8. History of pain which may be difficult to co-relate.

9. History of treatments which may be failed to relieve the symptoms. 

10. Difficult to identify the affected tooth.

Diagnosis

Successful diagnosis of CTS requires awareness of its existence and appropriate diagnostic tests. Pain on biting that ceases after the pressure has been withdrawn is a classical sign. Significantly, symptoms can be elicited when pressure is applied to an individual cusp⁵. Bite tests can be performed using various aids such as a toothpick, cotton roll, burlew wheel, wooden stick or the commercially available Tooth Slooth. Early diagnosis and intervention are important to limit the propagation of the crack, subsequent microleakage and involvement of  pulpal and periodontal tissues.

Treatment Plan

The treatment requirement of a cracked tooth is dependent on the position and extent of the fracture. An assessment of the stimuli, character and duration of the pain are influential guide for treatment. A decision flow chart indicating the treatment options available has been presented:

 

 

 

CASE REPORT

A 54-year-old male patient came to the Department of Conservative Dentistry & Endodontics with the chief complaint of pain in the left upper back tooth region since 1 month. Pain was sharp and intermittent in nature and increased on mastication. Clinical examination revealed:

• Presence of a crack on the buccal surface of 26(Fig 1)
• Presence of sinus tract opening on the buccal mucosa 
• No mobility 
• Periodontal probing depth of 3-4mm

On radiographic examination (Fig 2), it was noted that the crack was extending into the pulp along with periapical radiolucency. To further confirm the pathology a sinus tracing (Fig 3) was done.

Fig 1: Pre-operative picture: Buccal aspect of 26

 

                                       

     Fig 2: Pre-operative radiograph                                      Fig 3: Radiograph showing Sinus tracing

 

And the crack was further confirmed by bite test. Pain on biting that ceases after the pressure has been withdrawn - classical sign. Symptoms elicited when pressure was applied to the mesio-buccal cusp.

CBCT was taken to know the extent of the crack and thereby the prognosis of the tooth. On CBCT it was revealed that:

• the crack was extending buccolingually from the mesio-buccal cusp.
• from occluso-apically it is extending upto the pulpal floor.
• periapical radiolucency was also noted indicating a periapical lesion

 

 

1.     d)    
2.     f)    
3.     g)  

Fig 4(a-g): CBCT images of the AXIAL SECTIONS showing the extent of the crack and the periapical lesion surrounding the tooth

                                                                                                                                               

Fig 5: CBCT images of the SAGITTAL SECTIONS depicting the same

 

 

The treatment plan was to perform orthograde endodontic treatment followed by reinforcing the crack using flowable composite and ribbond fibers and post endodontic restoration.

In the first appointment, occlusal height reduction was done to relieve the tooth followed by banding of the tooth(Fig 6) in order to stabilize the crack. Then access opening was done under rubber dam isolation. Working length was determined(Fig 7). Cleaning and shaping were done with Heroshaper hand files upto 25 4% in relation to mesiobuccal and mesiolingual canals and 30 6% in relation to palatal canal. Ca(OH)₂ intracanal medicament was placed for 1 week and the access cavity sealed using Cavit.

 

 

                                           

 Fig 6: Occlusal reduction and Banding of the tooth                                 Fig 7: Working length determination

 

In the second recall visit after a week, healing of the sinus tract opening was noted. Under rubber dam isolation Ca(OH)₂ dressing was removed.Then the canals were dried using sterile paper points. Obturation was done using gutta-percha and Ca(OH)₂ based sealer (Ivoclar Vivadent Apexit Plus) (Fig 8 and 9).

 

                                                                                                       

        Fig 8: Post obturation radiograph                                         Fig 9: Picture taken post obturation and debanding showing the extent of crack

 

Crack was then sealed and reinforced with flowable composite and ribbond fibers(Fig 10). Access restoration was done with bulk fill composite(Fig 11). Follow up was done in the 1^st, 3^rd, and 6^th month after the endodontic treatment. At the 6th month follow up, the tooth was prepared for PFM crown and crown was placed(Fig 12 and 13).

 

                                                                                                         

    Fig 10: Sealing of crack using flowable composite and ribbond fiber                                            Fig 11: 3 month follow up

                        

Fig 12: Postoperative picture                                      Fig 13: 6 month follow up

 

DISCUSSION

Early detection of a cracked tooth is crucial for effective treatment. Early diagnosis can be challenging due to the complicated etiology. Proper dental history and visual examination plays a crucial role in the diagnosis. Other diagnostic methods for crack teeth include periodontal probing, radiographic examination, transillumination test, biting test, restorative removal, tactile examination, dyes, periapical tests, and vitality testing. 

A dental operating microscope (DOM) and loupes can help with visual assessment. A dental operating microscope can provide various magnification levels. Swept-source optical coherence tomography (SSOCT) is a promising method for detecting and analyzing enamel caries and early CTS.⁶ Ultrasonic systems, infrared thermography, and near-infrared 810 nm diode laser are some of the other diagnostic aids in the detection of cracks.

The treatment plan and success rate of cracked teeth depends on the extent and location of the cracks and also upon the severity of the symptoms. If the size of the involved portion of the tooth is relatively small and the crack does not involve the pulp, the tooth could be restored conventionally using resins, inlays, or crowns with periodic follow-ups.⁷ If the crack is extensive with prolonged symptoms, thermal hypersensitivity, and pulpal and periapical pathology, root canal treatment is the treatment of choice followed by crown placement and continuous follow-up.⁸ There are some cases in which the crack crosses the pulpal floor, extends deep into the bone, or symptoms persist even after root canal treatment; in such situations, extraction is usually the only viable option.^9-10

In this case, there was sharp and intermittent pain, which increased on mastication, and the crack was also extensive, which could be observed on the pulpal floor in the prepared access cavity. Also, the crack line was evident in the radiograph. The primary objective of the treatment plan was to stop the further propagation of the crack.¹¹ This was achieved by reducing the occlusal height of the tooth and banding of the tooth using stainless steel band. Root canal therapy was performed and the crack was sealed using flowable composite. The tooth was further reinforced by placing ribbond fibers along with composite as access restoration.^12-13 Finally, it was restored with a full coverage crown.

Root canal treatment is a viable nonsurgical treatment option for salvaging cracked teeth. Though information regarding survival rates of root-filled cracked teeth and prognosis assessment are scarce¹⁴, this case has shown stabilization of the crack, healing of the periapical lesion and the patient is asymptomatic. Thus, root canal treatment followed by crown serves as a viable treatment option for cracked tooth depending upon the extent of the crack with good success rates.

CONCLUSION

Cracked tooth syndrome has a wide variety of signs and symptoms, thus making the diagnosis difficult and complicated. Various techniques have been put forth in the management of cracked teeth to preserve, stabilize, and protect the affected tooth. In this case report, combined use of restoratives, banding of the tooth followed by endodontic and prosthodontic intervention have resulted in a favorable outcome.

Consent 

As per international standards or university standards, patient(s) written consent has been collected and preserved by the author(s).

Ethical Approval

As   per international   standard    or   university standards   written    ethical   approval   has    been collected and preserved by the author(s).

Authors’ contributions

This work was carried out in collaboration among all authors. Author KM had done the case. Authors BSKP and HMR had extended guidance throughout the case and helped in writing the paper. All authors read and approved the final manuscript.

Acknowledgement

I would  like  to   thank  my  guide   and  my  head   of the  department  for   guiding  and  supporting   me throughout the procedure and I would also like to thank department of oral medicine and radiology for helping me with the CBCT scans.

Competing Interests

Authors have declared that no competing interests exist.

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