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Available online at ajdhs.com 

Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2025 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided 

the original author and source are credited  

 

 

Cracked Tooth Syndrome: An Endodontic Triumph 

Khachane Chetan1*, Likhitkar Manoj2, Heda Anantkumar3, Mahalle Kavita4, Gupta Vyankatesh5, Khandelwal 
Akansha6 

1 P.G 3rd Year. Department of Conservative Dentistry and Endodontics, Dr. R. R. Kambe Dental College and Hospital, Akola. Maharashtra. India. 

2  Professor and HOD. Department of Conservative Dentistry and Endodontics, Dr. R. R. Kambe Dental College and Hospital, Akola. Maharashtra. India. 

3 Professor. Department of Conservative Dentistry and Endodontics, Dr. R. R. Kambe Dental College and Hospital, Akola. Maharashtra. India 

4 P.G 3rd Year. Department of Conservative Dentistry and Endodontics, Dr. R. R. Kambe Dental College and Hospital, Akola. Maharashtra. India. 

5 P.G 2nd Year, Department of Conservative Dentistry and Endodontics, Dr. R. R. Kambe Dental College and Hospital, Akola, Maharashtra, India.  

6 P.G 2nd Year, Department of Conservative Dentistry and Endodontics, Dr. R. R. Kambe Dental College and Hospital, Akola, Maharashtra, India. 

Article Info: 
_____________________________________________ 
Article History: 

Received   02 Dec 2024     
Reviewed  06 Jan 2025 
Accepted   25 Jan 2025 
Published 15 March 2025 

_____________________________________________ 
Cite this article as:  

Khachane C, Likhitkar M, Heda A, Mahalle K, 
Gupta V, Khandelwal A, Cracked Tooth 
Syndrome: An Endodontic Triumph, Asian 
Journal of Dental and Health Sciences. 2025; 
5(1):54-57    DOI: 
http://dx.doi.org/10.22270/ajdhs.v5i1.123           

Abstract 
_________________________________________________________________________________________________________________ 

A cracked tooth is one where a partial or complete fracture exists within the stress plane. Such 
fractures are more prevalent in patients over 40 years of age, with an incidence rate of 9.7% for 
cracks or incomplete tooth fractures with vital pulps. The average biting force in humans ranges 
from 45.7 kg/mm² in males to 36.4 kg/mm² in females, with the force ratio between molars, 
premolars, and incisors being 4:2:1, respectively. Occlusal forces commonly impose stress on a 
tooth, potentially causing higher energy instances within the stress plane during the mastication 
cycle. The functional prognosis and periodontal treatment requirements for a cracked or 
incompletely fractured tooth depend on the location and the extent of tooth structure intersected, 
along with its involvement in the stress plane. This case report highlights the diagnosis and 
management of a cracked maxillary first molar and identifies prognostic indicators, which largely 
depend on the extent of the fracture within the tooth structure. 

Keywords: Crack tooth, Orthodontic banding, CBCT, Longitudinal fractures, Endodontic treatment 

*Address for Correspondence:   

Chetan Khachane, P.G 3rd Year, Dr. R. R. Kambe Dental College and Hospital, Akola, Maharashtra, 444001, India. 

 

INTRODUCTION 

A cracked tooth refers to a tooth with a partial or 
complete fracture along a stress plane, often occurring in 
commonly affected teeth. Cracked tooth syndrome (CTS) 
can be defined as an incomplete fracture of unknown 
depth, originating in the crown, traversing the tooth 
structure, and potentially extending subgingivally to 
involve the pulp space and/or periodontal ligament. The 
fracture may pass through one or both marginal ridges 
and the proximal surfaces, and it may be confined to the 
crown or extend from the crown into the proximal root 
surface. The location, orientation, and severity of the 
crack significantly influence treatment decisions.1 
Central and apical occlusal cracks are more likely than 
fractured cusps to result in pulpal or periapical 
complications.2 

Gibbs first described the clinical symptoms of incomplete 
fractures in posterior teeth in 1954, calling it “cuspal 
fracture odontalgia.”3 Subsequently, Ritchey et al. 
documented cases of incomplete fractures leading to 
pulpitis in 1957.4 In 1964, Cameron coined the term 

"cracked tooth syndrome" to describe an incomplete 
fracture of a posterior tooth that involves the dentin and 
may extend to the pulp.5 This definition was later refined 
by Ellis as "a fracture plane of unknown depth and 
direction traversing the tooth structure, which, if not 
already involved, has the potential to progress and 
connect with the pulp and/or periodontal ligament."6 

The prevalence of CTS is unclear, but incidence rates 
between 34% and 74% have been reported.7 It most 
commonly affects individuals aged 30–50, with a higher 
prevalence in females.7 The mandibular molar is the 
tooth most often involved, followed by the maxillary 
premolar, maxillary molar, and mandibular premolar. In 
2006, Roh and Lee observed that cracks were more 
frequent in maxillary molars (57.2%) than mandibular 
molars (36.3%).8 

CTS can be classified into five categories, generally 
ranked from least to most severe: craze lines, fractured 
cusp, cracked tooth, split tooth, and vertical root 
fractures.9 The etiology of CTS is multifactorial. Lynch 
and McConnell identified four major contributing factors: 

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restorative procedures, occlusal factors, developmental 
factors, and miscellaneous factors.10 

Early diagnosis of cracked teeth is crucial, as delayed 
detection increases the risk of pulpal complications.11 
Additionally, associated bone defects may complicate 
future implant placement if the tooth is eventually lost.12 

The clinical signs and symptoms of CTS vary based on the 
location and extent of the fracture. Patients often report 
discomfort lasting several months, along with sharp pain 
when biting or consuming cold foods, beverages, or 
sugary substances. Rebound pain, felt when releasing 
pressure after biting fibrous foods, is a characteristic 
feature, although one study found chewing pain to be 
more common than rebound pain.13 Chronic pulpitis 
without clinical symptoms may develop due to 
microleakage of bacterial by-products and toxins. In 
cases where the crack involves the pulp, both pulpal and 
periodontal symptoms may arise. 

This case report provides an overview of the clinical 
features, diagnosis, and endodontic treatment of cracked 
teeth. 

CASE REPORT 

A 50-year-old male presented to the Department of 
Conservative Dentistry and Endodontics, complaining of 
pain in the upper right posterior region during chewing. 
He reported a history of traumatic bite a few weeks 
earlier. He had a cervical abrasion on a buccal surface of 
16. Upon clinical examination, crack lines were observed 
on the mesial and buccal surfaces of the tooth crown. 

(Fig.1a) The tooth responded positively to percussion 
and bite tests, and probing revealed a depth of 3 mm on 
the mesiobuccal aspect. Vitality testing with an electric 
pulp tester indicated no response in tooth 16. 
Radiographic imaging revealed a fracture line extending 
through the enamel, dentin, and pulp; however, the 
radiograph could not determine the exact extent of the 
fracture or provide significant additional findings (Fig. 
1b). 

The patient was informed about the option of cone beam 
computed tomography (CBCT) to assess the fracture's 
depth and its impact on the tooth's prognosis. The 
benefits of CBCT were explained, and assurances were 
given regarding minimal radiation exposure. After 
obtaining informed consent, CBCT (Vatech, PaX-Reve 3D 
Plus, pulse-type generator, 5 × 5 cm field of view, and 0.08 
mm voxel size) was performed to evaluate the fracture's 
apical extension and its proximity to the pulp (Figures 
4(a) and 4(b)). The imaging revealed that the fracture 
extended mesially and buccally, involving the 
mesiobuccal pulp horn, but did not extend apically below 
the alveolar bone level. (Fig. 1c & 1d) The prognosis was 
deemed favourable. Root canal treatment followed by 
crown placement was determined to be the most suitable 
treatment plan. The presence of acute pain and the 
suspected extension of the fracture to deeper areas of the 
root justified the use of CBCT for a precise diagnosis and 
treatment plan. The case was diagnosed as pulp necrosis 
with symptomatic apical periodontitis in tooth 16 due to 
a crack.

 

 

Figure 1: (a) Preoperative picture, (b) Preoperative radiograph, (c) Cone beam computed tomography (CBCT) showing 
the fracture line extending mesially and buccally, and (d) cracked line also towards the pulp space 

 

Treatment procedure: 
Occlusal reduction was performed before initiating root 
canal therapy on tooth 16. Upon access opening, necrotic 
pulp tissue was observed. The tissue was extirpated, and 
the tooth was visually examined using a magnifying loupe 
with LED illumination. A buccal crack line was identified 
extending into the dentin, terminating just above the pulp 
floor. Another crack line was seen on the occlusal fourth 
of the mesial wall. These cracks were removed with a no. 
1/4 round bur to a depth sufficient to eliminate the lines. 
The crack regions were etched and sealed with a flowable 
composite resin (COMPO-flo, D-tech). Orthodontic molar 
banding (0.180″ × 0.006″) was applied to stabilize the 
tooth. (Fig. 2) 

Canal instrumentation began with hand files using 
minimal force, followed by rotary instrumentation up to 
20/6% Neoendo Flex files. Irrigation was performed with 
3% sodium hypochlorite and saline. Calcium hydroxide 
intracanal medication was placed between 
appointments. Obturation was completed with gutta-
percha and zinc oxide sealer using the lateral 
condensation technique. Minimal force was applied 
during condensation to prevent further damage. The 
gutta-percha was trimmed at the orifice level, and post-
endodontic restoration was performed one week later 
using a glass ionomer cement liner, fiber-reinforced 
composite, and bulk-fill dentin bonding composite. (Fig.3 
a&b)

 

a b c d 



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Follow-up evaluations at one and three months showed 
no pathological changes upon clinical and radiographic 
examination. The orthodontic molar band was removed 
by creating a groove with a diamond bur and splitting it. 
The tooth was minimally prepared, and prosthetic 
rehabilitation was completed with a full-ceramic crown. 
A review at ten months confirmed that tooth 16 remained 
asymptomatic and functional, with an intact periapical 
area (Fig. 4&5). 

 

Figure 4: After crown placement 

 

Figure 5: Review after 10 months 

DISCUSSION 

Cracked tooth syndrome presents a diagnostic challenge, 
even for experienced dental professionals, due to its 
diverse and often atypical clinical signs and symptoms.14 
Early diagnosis is crucial, as it is associated with better 
restorative outcomes and prognosis.15 Various diagnostic 
methods are used to confirm cracks in teeth, such as 
visual examination under magnification, staining, 
transillumination, bite tests, autofluorescence, optical 
coherence tomography, quantitative percussion 
diagnostics, and laser detection. Radiographic 
techniques, particularly cone beam computed 
tomography (CBCT), are often superior to periapical 
radiographs for assessing crack extent. However, CBCT 

may still have limitations, especially in detecting cracks 
in endodontically treated teeth.16 With a resolution of 
approximately 80 μm, CBCT is not ideal for diagnosing 
cracks or detecting early vertical root fractures (VRFs).17 
An in vitro study by Yuan et al. showed that using 
meglumine diatrizoate as a contrast agent with CBCT 
enhances detection of hidden cracks compared to 
conventional methods.18 

In this case, the fracture line was visible on radiographs, 
and the treatment objective was to prevent further crack 
propagation. This was achieved through occlusal height 
reduction, crack sealing, and tooth stabilization using a 
stainless-steel band. Pane et al. demonstrated that 
stainless steel bands significantly reduce cuspal flexure 
and increase fracture resistance compared to teeth 
without bands.19 These bands act as a protective measure 
during treatment by absorbing forces and ensuring 
uniform stress distribution. As stainless steel has an 
elastic modulus higher than tooth structure, it transfers 
stress to the band material, thereby protecting the tooth. 
Care must be taken to avoid occlusal interference when 
applying bands. In this case, the crack's etiology was 
attributed to traumatic bite, as reported by the patient. 

The prognosis for a cracked tooth is more favourable 
when the crack is not visible or does not extend to the 
pulp chamber floor. In this case, visual examination under 
a 2.5× magnification loupe (Admetec) revealed a crack 
terminating just above the pulp floor. The tooth was 
diagnosed as non-vital, necessitating root canal 
treatment followed by prosthetic restoration. Treatment 
began with a guarded prognosis. Minor cracks can often 
be managed with bonded restorations or crowns, while 
deeper cracks with pulpal involvement require root canal 
therapy and crowns for structural reinforcement. 
Indirect composite onlays may also be an option, but full 
crowns are typically preferred for treating cracked tooth 
syndrome. 

Following banding and root canal therapy, the patient 
experienced relief from symptoms. Post-endodontic 
restoration included sealing the orifice with glass 
ionomer cement, replacing dentin with fiber-reinforced 
composite (EverX posterior, GC Europe), and applying a 
nanohybrid composite (Tetric EvoCeram, Ivoclar 
Vivadent, Inc.) for the occlusal laminate layer. Bonded 
restorations are effective in reinforcing weakened tooth 
structures. Fiber-reinforced composite has high flexural 

Figure 2: Clinical photograph after molar 
band placement. 

Figure 3: (a and b) Postoperative radiograph and 

photograph. 

a b 



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strength, minimal shrinkage, and the ability to arrest 
crack progression. The banding was retained for one 
month before being replaced with a full-ceramic crown. 
Full coverage restorations bind the tooth together, 
providing external compressive forces similar to banding, 
thus ensuring uniform stress distribution. Studies 
indicate that cracked teeth restored with full crowns after 
root canal treatment have higher survival rates and fewer 
complications compared to other restorations.20 

Clark and Caughman categorized cracked tooth 
prognosis into four groups based on the extent of the 
fracture:21 

• Excellent: 
(a) Cuspal fractures within the dentin angling from 
the faciopulpal or linguopulpal line angle of a cusp to 
the cemento-enamel junction or slightly below. 
(b) Horizontal fractures of a cusp not involving the 
pulp. 

• Good: Coronal vertical fractures running 
mesiodistally into dentin but not involving the pulp. 

• Poor: Coronal vertical fractures extending 
mesiodistally into dentin and pulp but confined to the 
crown. 

• Hopeless: Coronal vertical fractures passing 
mesiodistally through the pulp and into the root. 

A 10-month follow-up revealed that the treated tooth 
remained asymptomatic and functional, with an intact 
periapical area. 

Clinical Significance:  

Diagnosing cracked tooth syndrome is complex due to its 
varied signs and symptoms. A range of techniques can be 
used to manage cracked teeth effectively, focusing on 
preservation, stabilization, and protection. In this case, a 
combination of restorative procedures, banding, 
endodontic treatment, and prosthodontic intervention 
resulted in a favorable outcome. 

Acknowledgment: We would like to thank Dr. R.R. 
Kambe Dental College and Hospital and Department of 
conservative dentistry and endodontics.  

Conflicts of interest: There are no conflicts of interest. 

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