Therapeutic strategy for cracked teeth.

The management of cracked teeth represents a difficulty because their diagnosis is complex and there is no consensus concerning their treatment. The present article explains this pathology within enamel and dentin and also focuses on the clinical consequences of crack development in dental tissue. As cracks have both biologic and mechanical implications, a complete review of the literature on the subject has enabled the development of a comprehensive diagnostic approach to identify cracked teeth and optimize their management. The elements of diagnosis are the bite test, transillumination, the pulp sensitivity test, the periodontal test, radiologic examinations, removal of existing restorations, and the use of quantitative light-induced fluorescence. Finally, the management of biologic and mechanical imperatives relating to the treatment of cracked teeth has allowed the proposal of a reliable and reproducible therapeutic strategy based on two pillars: the arrest of bacterial infiltration using immediate dentin sealing, and the limitation of crack propagation using relative cuspal coverage. In this article, the proposed clinical protocol is explained through the use of a decision map and is illustrated by a clinical case example.

X-ray dark-field tomography reveals tooth cracks.

Cracked tooth syndrome (CTS) is a common clinical finding for teeth, it affects about 5% of all adults each year. The finding of CTS is favored by several risk factors such as restorations, bruxism, occlusion habits, and age. Treatment options range, depending on the severity, from no treatment at all to tooth extraction. Early diagnosis of CTS is crucial for optimal treatment and symptom reduction. There is no standard procedure for an evidence-based diagnosis up to date. The diagnosis is a challenge by the fact that the symptoms, including pain and sensitivity to temperature stimuli, cannot be clearly linked to the disease. Commonly used visual inspection does not provide in-depth information and is limited by the resolution of human eyes. This can be overcome by magnifying optics or contrast enhancers, but the diagnosis will still strongly rely on the practicians experience. Other methods are symptom reproduction with percussions, thermal pulp tests or bite tests. Dental X-ray radiography, as well as computed tomography, rarely detect cracks as they are limited in resolution. Here, we investigate X-ray dark-field tomography (XDT) for the detection of tooth microcracks. XDT simultaneously detects X-ray small-angle scattering (SAXS) in addition to the attenuation, whereas it is most sensitive to the micrometer regime. Since SAXS originates from gradients in electron density, the signal is sensitive to the sample morphology. Microcracks create manifold interfaces which lead to a strong signal. Therefore, it is possible to detect structural changes originating from subpixel-sized structures without directly resolving them. Together with complementary attenuation information, which visualizes comparatively large cracks, cracks are detected on all length-scales for a whole tooth in a non-destructive way. Hence, this proof-of principle study on three ex-vivo teeth shows the potential of X-ray scattering for evidence-based detection of cracked teeth.

Associations of types of pain with crack-level, tooth-level and patient-level characteristics in posterior teeth with visible cracks: Findings from the National Dental Practice-Based Research Network.

OBJECTIVES: The objective of this study was to determine which patient traits, behaviors, external tooth and/or crack characteristics correlate with the types of symptoms that teeth with visible cracks exhibit, namely pain on biting, pain due to cold stimuli, or spontaneous pain. METHODS: Dentists in the National Dental Practice-Based Research Network enrolled a convenience sample of subjects each of whom had a single, vital posterior tooth with at least one observable external crack (cracked teeth); 2858 cracked teeth from 209 practitioners were enrolled. Data were collected at the patient-, tooth-, and crack-level. Generalized estimating equations were used to obtain significant (p < .05) independent odds ratios (OR) associated with teeth that were painful for 10 outcomes based on types of pain and combinations thereof. RESULTS: Overall, 45% of cracked teeth had one or more symptoms. Pain to cold was the most common symptom, which occurred in 37% of cracked teeth. Pain on biting (16%) and spontaneous pain (11%) were less common. Sixty-five percent of symptomatic cracked teeth had only one type of symptom, of these 78% were painful only to cold. No patient-, tooth- or crack-level characteristic was significantly associated with pain to cold alone. Positive associations for various combinations of pain symptoms were present with cracks that: (1) were on molars; (2) were in occlusion; (3) had a wear facet through enamel; (4) had caries; (5) were evident on a radiograph; (6) ran in more than one direction; (7) blocked transilluminated light; (8) connected with another crack; (9) extended onto the root; (10) extended in more than one direction; or (11) were on the distal surface. Persons who were <65 yo or who clench, grind, or press their teeth together also were more likely to have pain symptoms. Pain was less likely in teeth with stained cracks or exposed roots, or in non-Hispanic whites. CONCLUSIONS: Although pain to cold was the most commonly noted pain associated with symptomatic cracked teeth, no patient-, tooth- or crack-level characteristic was significantly associated with pain to cold alone. Characteristics were only associated with pain on biting and/or spontaneous pain with or without pain to cold. CLINICAL SIGNIFICANCE: Although often considered the most reliable diagnosis for a cracked tooth, pain on biting is not the most common symptom of a tooth with a visible crack, but rather pain to cold.

Predicting extension of cracks to the root from the dimensions in the crown: A preliminary in vitro study.

BACKGROUND: In this study, the authors investigated whether extension of a tooth crack into the root can be predicted by the appearance of the crack in the crown in vitro. METHODS: The authors obtained 22 cracked teeth from 22 patients who underwent extraction, and they scanned the teeth using microcomputed tomography. The length and width of the crack on the occlusal surface (LOS and WOS, respectively) and the length of the crack on the proximal surface (LCPS) were measured on 3-dimensional reconstruction images. The pulp chamber roof was penetrated and removed. A crack line visible under the microscope only on the access cavity wall rather than extending to the bottom of the pulp chamber was termed a "nonroot crack." A crack seen at the bottom of the pulp chamber or root wall was termed a "root crack." The authors analyzed the data using Pearson correlation coefficients and receiver operating characteristic curves. RESULTS: There was a significant correlation between the LOS and LCPS (correlation coefficient, 0.782; P < .001) and between the WOS and LCPS (correlation coefficient, 0.651; P < .05). The LCPS increased by 1.195 millimeters for every 1-mm increase in the LOS. The area under the receiver operating characteristic curve was 0.839 (95% confidence interval, 0.659 to 1.000) for LOS and 0.760 (95% confidence interval, 0.557 to 0.964) for WOS. CONCLUSIONS: The extent of a crown crack may indicate how far the crack extends to the root. Both the LOS and WOS may be valuable for assessing whether a crack involves the root, although the LOS seems to be more useful. PRACTICAL IMPLICATIONS: The dimensions of a crack in a crown provide a helpful approach for predicting the depth of the crack and its likely prognosis.

Detection and Analysis of Enamel Cracks by Quantitative Light-induced Fluorescence Technology.

INTRODUCTION: The ability to accurately detect tooth cracks and quantify their depth would allow the prediction of crack progression and treatment success. The aim of this in vitro study was to determine the capabilities of quantitative light-induced fluorescence (QLF) technology in the detection of enamel cracks. METHODS: Ninety-six extracted human teeth were selected for examining naturally existing or suspected cracked teeth surfaces using a photocuring unit. QLF performed with a digital camera (QLF-D) images were used to assess the ability to detect enamel cracks based on the maximum fluorescence loss value (ΔFmax, %), which was then analyzed using the QLF-D software. A histologic evaluation was then performed in which the samples were sectioned and observed with the aid of a polarized light microscope. The relationship between ΔFmax and the histology findings was assessed based on the Spearman rank correlation. The sensitivity and specificity were calculated to evaluate the validity of using QLF-D to analyze enamel inner-half cracks and cracks extending to the dentin-enamel junction. RESULTS: There was a strong correlation between the results of histologic evaluations of enamel cracks and the ΔFmax value, with a correlation coefficient of 0.84. The diagnostic accuracy of QLF-D had a sensitivity of 0.87 and a specificity of 0.98 for enamel inner-half cracks and a sensitivity of 0.90 and a specificity of 1.0 for cracks extending to the dentin-enamel junction. CONCLUSIONS: These results indicate that QLF technology would be a useful clinical tool for diagnosing enamel cracks, especially given that this is a nondestructive method.

The effect of using RC prep during root canal preparation on the incidence of dentinal defects.

INTRODUCTION: The purpose of this in vitro study was to evaluate the effect of using RC Prep (Well-Prep, Vericom Co, Anyang, Korea) during root canal preparation on the incidence of defects in root canal walls. METHODS: One hundred extracted mandibular incisors with single canals were randomly divided into 1 control group and 4 experimental groups (n = 20). The teeth in group 1 (control) were coronally flared with Gates Glidden drills (Mani, Japan), but no further preparation was made. All teeth in the experimental groups were first coronally flared with Gates Glidden drills and then prepared similarly by means of ProTaper instruments (Dentsply Maillefer, Ballaigues, Switzerland). The difference between the experimental groups was the following: in group 2, saline was used as an irrigation solution without the application of RC Prep; in group 3, teeth were irrigated with saline, and RC Prep was also applied to canals before the insertion of each file; in group 4, sodium hypochlorite (NaOCl) was used for irrigation without the application of RC Prep; and in group 5, both NaOCl and RC Prep were used. The apical root surface and horizontal sections 3, 6, and 9 mm from the apex were observed under a microscope. The presence of cracks was noted. The chi-square test and Fisher exact test were used for statistical analysis of differences between and among the groups. RESULTS: A significant difference was found between and among the 5 groups (P < .05). Group 4 (NaOCl), which had the highest number of cracked teeth, was significantly different from group 1 (control) (P < .05). RC Prep, with both saline and NaOCl, had no significant effect on the incidence of microcrack formation (P > .05). When data were pooled, regardless of whether RC Prep was used, there was a significant difference between saline (groups 2 + 3) and NaOCl (groups 4 + 5) (P < .05). CONCLUSIONS: RC Prep was unable to reduce the risk of dentinal defects. NaOCl caused more defects compared with saline.

The cracked tooth: histopathologic and histobacteriologic aspects.

INTRODUCTION: The diagnosis and treatment planning of cracked teeth depend on the understanding of how cracks affect the surrounding tissues. This study evaluated the dentin and pulp conditions in teeth affected by cracks and attrition. METHODS: Specimens under investigation included 12 cracked posterior teeth and 8 teeth with severe attrition. These teeth were obtained consecutively in a private practice and were extracted for reasons not related to this study. Teeth were processed for histopathologic and histobacteriologic analyses. RESULTS: Cracks were histologically detected in all specimens, including the teeth with severe attrition. The cracks in all teeth were colonized by bacterial biofilms. One tooth showed several craze lines in the enamel, one of which reached dentin to a shallow depth. In some teeth, the crack ended in the dentin. Dentinal tubules were invaded by bacteria, especially when the crack extended perpendicularly into the dentin. Severe accumulations of inflammatory cells were present in the pulp zone subjacent to tubules involved with the crack. In many cases, the crack extended to the pulp, leading to reactions with intensities ranging from acute inflammation to total pulpal necrosis. Symptoms occurred in most cases in which the pulp was affected. In some cases, polymorphonuclear neutrophils were seen migrating from the pulp into the crack space and facing the bacterial biofilm located therein. Severe pulp reactions were also observed when the crack extended to the pulp chamber floor. CONCLUSIONS: Cracks are always colonized with bacterial biofilms. The pulp tissue response varies according to the location, direction, and extent of the crack.

Different treatment protocols for different pulpal and periapical diagnoses of 72 cracked teeth.

INTRODUCTION: The treatment plan for cracked teeth depends on the extent of the crack. A tooth with an extensive crack of long duration may be more likely to require root canal treatment. The purpose of this study was to analyze the characteristics of cracked teeth and to assess the outcome of different treatment protocols depending on the pulpal and periapical diagnoses. METHODS: Seventy-two of 476 crown-restored teeth were diagnosed as cracked teeth. The location of the cracked teeth, age and sex of the patients, restoration materials, a diagnosis of pulp and apex, and the periodontal probing depth were analyzed. Cracked teeth were treated by different treatment protocols depending on the pulpal and periapical diagnoses. RESULTS: Mandibular first molars (27.8%) were the most frequently involved teeth followed by maxillary first molars (25%), maxillary second molars (22.2%), and mandibular second molars (19.4%). The most frequently involved ages were 40-49 and 50-59 years. Cracks occurred mainly in nonbonded restorations such as gold (26.4%) and amalgam (12.5%), and 48.6% of cracks were found in intact teeth. In this study, 60 teeth (83.3%) were treated with root canal treatment before being restored with a permanent crown, and only 12 teeth (16.7%) remained vital and were restored with a permanent crown without root canal treatment. The proportion of teeth treated with root canal treatment increased along with a deep periodontal probing depth corresponding to the crack. The prognosis was less favorable in cracked teeth with a deep probing depth. CONCLUSIONS: In this study, the proportion of root canal treatment in the cracked teeth was higher than other studies. Many patients are referred to an endodontist in a university hospital after a long time has passed since the symptom started. Early recognition can help to avoid the propagation of a crack into the pulp chamber or subgingival level. Furthermore, it is important to investigate factors related to cracked teeth and develop different treatment protocols for different pulpal and periapical diagnoses.

Correlation between cuspal inclination and tooth cracked syndrome: a three-dimensional reconstruction measurement and finite element analysis.

BACKGROUND/AIM: This paper explored the correlation between cuspal inclination and tooth cracked syndrome by measuring and reconstructing the cuspal inclinations of cracked maxillary first molars through three-dimensional (3D) finite element analysis (FEA). MATERIAL AND METHODS: The cuspal inclinations of 11 maxillary left first molars with cracked tooth syndrome and 22 intact controls were measured by 3D reconstruction. The mean values of each group were used to construct two 3D finite element models of maxillary first molar for comparing stress distribution under the loads of 200N at 0°, 45°, and 90°, respectively, to the tooth axis. RESULTS: There was statistically significant difference in the cuspal inclination between the incompletely fractured group and the intact control group ( P  < 0.001), which was 5.5-6.7 degrees steeper. The model from the mean cuspal inclinations of the incompletely fractured molars showed the maximum tensile stress of 5.83, 10.87, and 25.32 MPa, respectively, in comparison with 5.40, 8.49, and 22.76 MPa for the model of the control group. Besides, the tensile stress was mainly at the center groove and cervical region of the molar model. CONCLUSIONS: Steeper cuspal inclinations resulted in an increment in tensile stress that was mainly at the center groove and cervical region of the molar model under equivalent loads. Higher unfavorable tensile stress was generated with the increasing horizontal component load on the cuspal incline. This indicates an effective reduction of cuspal inclination to the compromised teeth for dentists.

The reduction in fatigue crack growth resistance of dentin with depth.

The fatigue crack growth resistance of dentin was characterized as a function of depth from the dentino-enamel junction. Compact tension (CT) specimens were prepared from the crowns of third molars in the deep, middle, and peripheral dentin. The microstructure was quantified in terms of the average tubule dimensions and density. Fatigue cracks were grown in-plane with the tubules and characterized in terms of the initiation and growth responses. Deep dentin exhibited the lowest resistance to the initiation of fatigue crack growth, as indicated by the stress intensity threshold (ΔK(th) ≈ 0.8 MPa•m(0.5)) and the highest incremental fatigue crack growth rate (over 1000 times that in peripheral dentin). Cracks in deep dentin underwent incremental extension under cyclic stresses that were 40% lower than those required in peripheral dentin. The average fatigue crack growth rates increased significantly with tubule density, indicating the importance of microstructure on the potential for tooth fracture. Molars with deep restorations are more likely to suffer from the cracked-tooth syndrome, because of the lower fatigue crack growth resistance of deep dentin.

Hunter-Schreger Band patterns and their implications for clinical dentistry.

Hunter-Schreger Bands (HSBs) are an optical phenomenon visualised when a cut or fractured enamel surface is viewed under reflected light. These bands demonstrate the synchronous decussation of individual or groups of enamel prisms. While the role of HSB patterns has been investigated in comparative anatomical studies, until recently there has been little consideration of HSB patterns in human teeth. The aim of this paper is to consider the significance of HSB patterns in the human dentition and in relation to clinical dentistry. It is concluded that within the human dentition, HSB patterns have evolved to optimise resistance to attrition, abrasion and tooth fracture. It appears that certain aspects of HSB packing densities and distributions have beneficial roles in enamel bonding. Hunter-Schreger Band patterns seem to passively facilitate conditions such as abfraction and cracked tooth syndrome.

Crack propagation in teeth: a comparison of perimortem and postmortem behavior of dental materials and cracks.

This study presents a new method for understanding postmortem heat-induced crack propagation patterns in teeth. The results demonstrate that patterns of postmortem heat-induced crack propagation differ from perimortem and antemortem trauma-induced crack propagation patterns. Dental material of the postmortem tooth undergoes dehydration leading to a shrinking and more brittle dentin material and a weaker dentin-enamel junction. Dentin intertubule tensile stresses are amplified by the presence of the pulp cavity, and initiates crack propagation from the internal dentin, through the dentin-enamel junction and lastly the enamel. In contrast, in vivo perimortem and antemortem trauma-induced crack propagation initiates cracking from the external surface of the enamel toward the dentin-enamel junction where the majority of the energy of the crack is dissipated, eliminating the crack's progress into the dentin. These unique patterns of crack propagation can be used to differentiate postmortem taphonomy-induced damage from antemortem and perimortem trauma in teeth.

Cracked tooth syndrome: characteristics and distribution among adults in a Nigerian teaching hospital.

This study highlighted the characteristics and distribution of cracked tooth syndrome (CTS) and the associated factors in adult attendees in the University of Nigeria Teaching Hospital. Three hundred seventy patients aged 18 years to 77 years with CTS-like conditions were included and studied over 12 months. The following information was recorded: suspected tooth and the dental arch, restorative status of the tooth, age and sex of the patient, results of bite test and transillumination, and the pulpal and periapical status of the tooth. CTS was seen most often in the 41 to 50 years age band (36.4%), in molars (63.6%), and in the maxillary arch (51.5%). Also, it was more frequent in men (55.8%). About 82% of CTS occurred in amalgam-restored teeth. All cases had a positive response to the bite test and a normal response to the electric pulp test. Only 10% gave a positive history of masticatory accident as against none with history of bruxism habits. It was concluded that patients with unexplained pain in a vital, amalgam-restored tooth (especially in maxillary molars), with or without a history of a masticatory accident, may have a cracked or fractured tooth.

Definitive diagnosis of early enamel and dentin cracks based on microscopic evaluation.

UNLABELLED: The diagnoses of cracked teeth and incomplete coronal fracture have historically been symptom based. The dental operating microscope at 16x magnification can fundamentally change a clinician's ability to diagnose such conditions. Clinicians have been observing cracks under extreme magnification for nearly a decade. Patterns have become clear that can lead to appropriate treatment prior to symptoms or to devastation to tooth structure. Conversely, many cracks are not structural and can lead to misdiagnosis and overtreatment. Methodic microscopic examination, an understanding of crack progression, and an appreciation of the types of cracks will guide a doctor to make appropriate decisions. Teeth can have structural cracks in various stages. To date, diagnosis and treatment are very often at end stage of crack development. CLINICAL SIGNIFICANCE: This article gives new guidelines for recognition, visualization, classification, and treatment of cracked teeth based on the routine use of 16x magnification. The significance of enamel cracks as they relate to dentinal cracks is detailed.

The cracked tooth syndrome.

The purpose of this article is to review the clinical features, diagnosis and management of the cracked tooth syndrome (CTS). The condition refers to an incomplete fracture of a vital posterior tooth that occasionally extends into the pulp. A lack of awareness of the condition coupled with its varied clinical features can make diagnosis of CTS difficult. Common symptoms include an uncomfortable sensation or pain from a tooth that occurs while chewing hard foods and which ceases when the pressure is withdrawn. The patient is often unable to identify the offending tooth or quadrant involved, and may report a history of numerous dental procedures with unsatisfactory results. Successful diagnosis and management requires an awareness of the existence of CTS and the appropriate diagnostic tests. Management options depend on the nature of the symptoms and extent of the lesion. These options include routine monitoring, occlusal adjustments, placement of a cast restoration and endodontic treatment. A decision flowchart indicating the treatment options available to the dental practitioner is presented.

Type and incidence of cracks in posterior teeth.

STATEMENT OF PROBLEM: The use of magnified vision in the operatory has enhanced the early diagnosis of structural defects in the dentition and in existing restorations. There is little in the literature to guide the clinician on the significance of cracks and other interruptions in the integrity of teeth. PURPOSE: This study characterized the type and incidence of cracks in posterior teeth and identified possible etiologic factors. MATERIAL AND METHODS: An observational cross-sectional survey of 51 patients from a private practice examined during an 18-month period was used to identify 4 types of cracks in posterior teeth. The study identified both patient- and tooth-level variables present in each patient examined. The data were subjected to statistical analysis to determine whether correlations existed between the variables and cracks. RESULTS: Cracks in teeth were shown to have chronicity and can be classified according to appearance. Variables such as the presence of a Class I or II restoration and the presence of excursive interferences were shown to significantly increase (P< .0001) the chances of a crack being present. Combinations of variables, such as interferences and a restoration, also increased the chance of a crack being present. CONCLUSION: Within the limitations of this study, the presence of cracks in teeth was associated with the placement of a Class I or II restoration and with the presence of excursive interferences. Age played a role in the presence of stained or symptomatic cracks, which suggests that cracks have chronicity. Although many questions remain regarding prevention, it is evident that protecting teeth from excursive interferences and parafunction may thwart premature breakdown.

Incomplete tooth fracture--proposal for a new definition.

Many terms have been used to describe incomplete tooth fractures. This paper reviews them, discusses the clinical features of incomplete tooth fractures and proposes a clinically representative definition.

[A newly developed method for taking pictures of tooth crown cracks for clinical records].

It is very important to examine fine cracks on the crown surface of traumatized tooth in the dental clinic because the presence of these cracks may cause discomfort or hypersensitivity of the tooth. By the emission of routinely used light, it is difficult to illuminate cracks, and the usual intraoral photography using strobe light emission is not useful to make records of cracks in most cases. In the present study, a method for taking pictures to record tooth crown cracks was newly developed using LED as a light source, and applied to patients with traumatized teeth in the dental clinic. The results were as follows: 1. Cracks on the tooth surface could be confirmed with the LEDs of all the colors used in this study. However, the blue LED enabled cracks in the incisal edge part to be more easily confirmed, and the white LED enabled cracks in the cervical part to be more easily confirmed. 2. Cracks of multiple modalities on the tooth surface was illuminated more often when the LED light was emitted at 45 degrees to the axis of the tooth than 90 degrees. 3. The light exposure field became wider by the use of the LED of diameter 5 mm than that of diameter 3 mm. However, the LED of diameter 3 mm was more favorable than that of diameter 5 mm for the observation of the cracks because the former could more easily change the direction of light emission.

Preservation of the roots--management and prevention protocols for cracked tooth syndrome.

It is essential that symptomatic fractures of teeth be suitably diagnosed to prevent propagation of the fracture and continuation of the symptoms. The importance of understanding the mechanism and progression of fractures within teeth is essential when considering the management of fractures within teeth. The relation of the fracture line to the pulp, periodontal ligament and root will influence the management protocols for the involved teeth. When does a Cracked Tooth Syndrome (CTS) become a cracked tooth i.e., unrestorable? Consideration is also required regarding when endodontic treatment should be commenced. Further, suitable-coronal restoration of teeth is required to prevent propagation of the fracture line and persistence of the symptoms. Patients diagnosed with CTS should be counselled in strategies to prevent CTS in other teeth.