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

Copyright  © 2024 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
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the original author and source are credited  

 

 

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 

Article Info: 
_____________________________________________ 
Article History: 

Received   05 June 2024     
Reviewed  03 July 2024 
Accepted   28 July 2024 
Published 15 September 2024 

_____________________________________________ 
Cite this article as:  

Mathew K, Rao HM, Prasad BSK, Rehabilitation of a 
Cracked Tooth: A Case Report, Asian Journal of 
Dental and Health Sciences. 2024; 4(3):5-10                                                                   

DOI: http://dx.doi.org/10.22270/ajdhs.v4i3.85      

Abstract 
_________________________________________________________________________________________________________________ 

A cracked tooth is a tooth in which there exists a partial or complete fracture of a stress plane. The 
prevalence of cracked teeth is relatively more in patients over 40 years of age. The incidence of 
cracks or incomplete tooth fracture with vital pulps is 9.7%. The average biting loads in humans 
range from 45.7kg/mm2 (males) to 36.4kg/mm2 (females) and the force ratio between molars, 
premolars, and incisors is 4:2:1 respectively.   

A tooth stress plane results from occlusal forces that are commonly imposed on that tooth. This may 
cause an instance of higher energy to occur within the stress plane during masticatory cycle. The 
functional prognosis and periodontal treatment requirements of a cracked or incompletely 
fractured tooth depend on the location and amount of tooth structure intersected along with 
involvement in the stress plane. 

This case report highlights the diagnosis and management of a cracked maxillary first molar and 
identifies the prognostic indicators, which are largely dependent on the extent of the fracture within 
the tooth structure. 

Keywords: Crack tooth; Orthodontic banding; Ribbond; Bite test; Transillumination 

*Address for Correspondence:   

Dr. Kshema Mathew, Post Graduate Student, 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.

 

 

 

 

 

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Mathew et al.                                                                                                                                 Asian Journal of Dental and Health Sciences. 2024; 4(3):5-10 

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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:



Mathew et al.                                                                                                                                 Asian Journal of Dental and Health Sciences. 2024; 4(3):5-10 

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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



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    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

 

a)     d)     

b)     f)     

c)     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 

 



Mathew et al.                                                                                                                                 Asian Journal of Dental and Health Sciences. 2024; 4(3):5-10 

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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 1st, 3rd, 

and 6th 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, 



Mathew et al.                                                                                                                                 Asian Journal of Dental and Health Sciences. 2024; 4(3):5-10 

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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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https://doi.org/10.1186/s12903-017-0434-x
https://doi.org/10.4103/2229-516X.165376
https://doi.org/10.1111/j.1600-9657.2006.00347.x
https://doi.org/10.1111/j.1600-9657.2006.00347.x
https://doi.org/10.1007/s40496-015-0045-z
https://doi.org/10.1111/j.1834-7819.1990.tb05872.x
https://doi.org/10.14219/jada.archive.1999.0254
https://doi.org/10.1016/j.jdent.2013.11.025
https://doi.org/10.1016/0022-3913(92)90405-Y
https://doi.org/10.1016/0022-3913(92)90405-Y
https://doi.org/10.1016/j.joen.2019.03.015

