Restorative

    Cards (29)

    • Cracked Tooth Syndrome
      An incomplete fracture of a vital posterior tooth that involves the dentine and occasionally extends to the pulp
    • Cracked Tooth Syndrome
      • 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
    • Types of cracked tooth
      • Craze lines
      • Fractured cusp
      • Cracked tooth
      • Split tooth
      • Vertical root fracture
    • Craze lines
      Asymptomatic as the fracture is contained within enamel
    • Fractured cusp
      Complete or incomplete fracture extending to the cervical third or the root surface. The pulp is normally vital, with mild symptoms on biting and to cold
    • Cracked tooth

      Incomplete 'green-stick' fracture which usually extends mesio-distally, but may also run bucco-lingually in posterior teeth
    • Split tooth
      The end result of a cracked tooth, which normally has a poor prognosis as the tooth is split into two separate fragments
    • Vertical root fracture
      Crack initiated at the root level, usually in a bucco-lingual direction. The crack may be complete or incomplete and almost all cases have a history of root canal treatment
    • Epidemiology of cracked tooth syndrome
      • 30-60 year old adult patients
      • Male = Female
      • May become more frequent in the future as people are retaining their teeth for longer
      • Mandibular molars> maxillary premolars and molars> mandibular premolars
      • Cracked teeth often have restorations (large amalgams), 35% are reported to be sound
    • Aetiology of cracked tooth syndrome
      • Excessive forces applied to a healthy tooth
      • Physiological forces applied to a weakened tooth
    • Factors contributing to cracked tooth syndrome
      • Restorative procedures (pins, excessive removal of tooth structure, over contouring, improper placement of composite)
      • Occlusal factors (masticatory accident, parafunctional habits)
      • Developmental factors (localised structural weakness, deep occlusal grooves, steep cusp angles, prominent mesio-palatal cusps)
      • Miscellaneous (aging dentition, tongue studs)
    • Symptoms of cracked tooth syndrome
      • Cold sensitivity/sweet sensitivity
      • Sharp pain on biting hard or tough food particularly on release (rebound pain)
      • Often not well localised
      • If crack propagates into pulp chamber, symptoms of irreversible pulpitis or apical periodontitis may ensue
      • If fracture progresses to root, there may be localised periodontal breakdown
    • Diagnosis of cracked tooth syndrome
      Can be difficult as symptoms vary, take a detailed pain history, early diagnosis can improve prognosis
    • Differential diagnosis of cracked tooth syndrome
      • Dentine hypersensitivity
      • Reversible pulpitis
      • Post-op sensitivity/ 'high spots' on restorations
      • Galvanic pain
      • Atypical facial pain
    • Diagnostic tests for cracked tooth syndrome
      • Visual investigation (magnification and illumination)
      • Trans-illumination
      • Dyes (e.g. methylene blue)
      • 'Bite tests' (tooth sleuth)
      • Removing existing restorations
      • Radiographs have limited use
      • Copper bands/SS orthodontic bands can confirm diagnosis
      • Probing for localised isolated periodontal defects
    • Cracked teeth may be hyper-sensitive to cold stimuli due to pulpal inflammation
    • Cracked teeth are rarely tender to percussion (may elicit response to lateral percussion)
    • Radiographs are of limited use as fractures tend to propagate in a mesio-distal direction, parallel to the plane of the film
    • Restoration removal can reveal the crack lines of a cuspal fracture plane
    • Prognosis factors for cracked tooth syndrome
      • Location and extent of crack
      • Restorative status of the tooth
      • Functional forces applied to the tooth
    • Excellent prognosis
      Crack is confined to dentine layer, runs in horizontal direction not involving pulp, limited to single marginal ridge
    • Poor prognosis
      Involve both marginal ridges, communicate with dental pulp, or extend vertically through pulp/involve sub-pulpal floor
    • Hopeless prognosis
      Complete mesio-distal fractures, fractured segment cannot be removed or exposed (subgingival)
    • 20% of cracked teeth will require root canal treatment, cracked teeth which have been root treated have a relatively high failure rate (14.5%)
    • Immediate/intermediate management of cracked tooth syndrome
      • Occlusal adjustment
      • Orthodontic band/copper ring/temporary crown
      • Remove restoration and place composite resin +/- cuspal coverage or an amalgam onlay
    • Longer term management options for cracked tooth syndrome
      • Direct: Amalgam overlays, Composite overlays
      • Indirect: Conventional/adhesive metal onlay, Ceramic onlay, Composite onlay, Full coverage crown
    • The aim of restorative therapy is to immobilise the segments of the tooth that move on loading
    • Early diagnosis of cracked tooth syndrome improves prognosis
    • Using an orthodontic band/composite splint can help confirm diagnosis as symptoms resolve
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