TOOTH

INFRACTION
 CONTENTS

•Introduction
•Definition
•Classification
•Incidence
•Etiological factors
•Patterns and variants
•Signs and symptoms
•Diagnosis
•Sequelae
•Management
•Conclusion
INTRODUCTION
•Crown fractures are more apt to occur as a result of a high-velocity
impact against the tooth with less resulting damage to the
supporting tissues.

•Blows of low velocity are less apt to fracture the crown but cause
the greatest damage to the supporting tissues- Andreason
 The severest pulpal reaction is often seen in teeth with the
least apparent injury.

 Frequently teeth sustaining fracture retain their vitality

while the adjacent traumatized teeth, which remain intact,
undergo pulpal necrosis.
 DEFINITION

Crown infraction is an incomplete fracture or crack of enamel

without loss of tooth structure.

Either occur naturally or develop secondary to trauma and

appears as craze lines running parallel with the direction of the
enamel prisms and terminating at the dentin-enamel junction.

Often associated with luxation injuries

SYNONYMS
Hairline fracture
Split root syndrome
Crown craze
Cuspal fracture
Greenstick fracture
Tooth structure cracks
Fissured fracture
Incomplete crack/craze lines
Cuspal fracture odontalgia
Chronological development of terms and definitions for tooth
fractures where there is no obvious separation of the fragments

1954 Cuspal Fracture Odontalgia (Gibbs) — describes symptoms

associated with ITFs
1954 Fissured Fracture (Thoma)— ‘a crack in the crown of the
tooth. It may involve enamel alone or both the enamel and
dentine’
1957 Incomplete Tooth Fracture (Ritchey, Mendenhall & Orban)
1957 Fissural Fracture (Down)— ‘fractures involving enamel and
dentine without loss of tissue’
1961 Crack Lines (Sutton)— ‘a break in the continuity of the
tooth revealed only by the presence of a visible transverse line’
1962 Greenstick Fractures (Sutton)— ‘a fracture line forms in a
part of a tooth underlying a cusp. The fractured part remains in
place except when forced away from the central sulcus by a
lateral force sufficiently strong to produce bending of that part
of the tooth which is between the affected cusp and the root’

1964 Cracked Tooth Syndrome (Cameron)— describes a triad of

signs and symptoms of ITFs

1972 Hairline Fracture (Wiebusch)

1973 Incomplete Crown-Root Fracture (Hiatt)

1976 Split-Root Syndrome (Silvestri)

1977 Incomplete Tooth Fracture (Maxwell & Braly) — ‘a fracture

of tooth structure which extends into dentine but in which the
tooth remains grossly intact’

1981 Enamel Infraction (Andreasen) —‘an incomplete fracture

(crack) of the enamel without loss of tooth substance’ and
‘lines in enamel which do not cross the amelodentinal junction’

1981 Hairline Tooth Fracture (Caulfield)

1981 Crown Craze/Crack (Johnson) — ‘injury ... of enamel
without loss of tooth structure’

1983 Crack Lines, Craze Lines, Tooth Structure Cracks (Abou-

Rass)
Tooth Structure Cracks — ‘a line that breaks or splits the
continuity of tooth dentinal surface but does not
perceptibly separate that surface’
Craze Lines — ‘located in coronal enamel’

1984 Incomplete Tooth Fracture (Luebke) — ‘a demonstrable

fracture but with no visible separation of the segments
along the plane of the fracture
1984 (Kruger) Cracked cusp syndrome

1986 (Brännström) Dentin crack syndrome

1988 (Williams) Incomplete vertical tooth fracture

1989 (Lost et al)Tooth infraction

1989 (Schweitzer) Odontiatrogenic tooth fracture

1990 (Ehrmann & Tyas) Cracked tooth syndrome -‘Incomplete
fracture of a vital posterior tooth involving the dentin and
possibly the dental pulp’
1998 (Zuckerman) Cracked tooth- ‘Fractured segments are still
joined to one another by a portion of that tooth through which
the fracture has not yet extended’
2001 (Ellis) Incomplete tooth fracture
 American Association of Endodontists
Classification of Cracked teeth:

Classification Originate Direction Symptoms Pulp Status Prognosis

• Craze Line • Crown • Variable • None • Vital •Excellent

• Fractured • Crown • M-D and/or • Mild and only • Usually vital •Good
cusp F-L to biting and
cold
• Crown±Root • M-D often • Variable •Questionable
• Cracked Central • Acute pain
: Dependent
tooth on biting
Occasionally on depth and
sharp pain to extent of the
cold crack
• Split tooth • Crown+Root • M-D • Often root •Poor unless
• Marked pain filled Mainly crack
on chewing root filled terminates
just
subgingivally

• Vertical root • Roots • F-L •Poor: Root

fracture resection in
• Vague pain
• Mimics multi-rooted
periodontal teeth
pain
Luebke Classification
Class 1 - Incomplete, supra-osseous with no periodontal
defect
Class 2 - Incomplete, intra-osseous with a minor
periodontal defect
Class 3 - Complete or incomplete, intra-osseous with a
major periodontal defect
 Nature of tooth fracture: By Luebke
Complete

Incomplete
Types of tooth fracture:
INCIDENCE
 Age: Most common in 30-50 yrs of age

 Sex:Men:women=1:1

 Site:Mandibular second molars > Mandibular first

molars > Maxillary premolars

 Direction: Mesiodistally > Buccolingually

ETIOLOGICAL FACTORS
Age related
Tooth related
Pathological habits
Iatrogenic(due to endodontic procedures )
 Patterns
 ITFs may involve a combination of crown and root
structure.
 Depth and direction of the fracture plane cannot usually be

clinically determined.
 Depth and direction will influence:

• To what extent enamel and dentine are involved and

whether the pulp chamber is breached and
• If the fracture plane is ‘on course’ to penetrate the external
root surface.
 VARIANTS
I
 Those that do not involve
the pulp.
 Those in which irreversible
pulpal damage has occurred
II

 Supra- and intra-osseous

III
Vertical
Oblique
 SYMPTOMS
Depends upon the stage

Main symptom is pain

Pain primarily arise from:
1. Stimulation of the dentinal tubules following
minute separation of the fracture
2. From irreversible pulpitis resulting from
microleakage along the fracture plane

Pain may be due to:

• Pulpal effect
• Piezoelectric effect
CHARACTERISTICS OF PAIN
 Sudden
 Momentary
 Only during biting
 Not relieved just by desensitisation
 Increases as occlusal forces increases and when the
pressure is relieved
 DIAGNOSIS
 Usual detection is difficult
 Clinical detection depends upon:

Length and width of fracture

Type of illumination
Use of contrast media
METHODS OF DIAGNOSIS
 History

 Vision enhancers

 Symptom reproducers
  Magnifying loupes

Transilluminators and fibre

optic sources
 Assessment cavity


Periodontal probe or tissue


flap
CLINICAL DETECTION-Bite Tests
Patient is instructed to bite on various items such
as
 Tooth pick
 Cotton roll
 Burlew wheel

 Woodenstick
 Commercially available tooth slooth.
Pain occurs when Pain occurs when
occlusal forces are occlusal forces are
increased relieved
CONFIRMATION OF DIAGNOSIS
Disclosing dyes Gentian Violet or methylene blue
SEQUELAE
 Cuspal fracture

 Partial or complete root fractures

 Pulpal pathosis
 Incomplete longitudinal fracture
MANAGEMENT
 Treatment objectives: to maintain structural integrity
and pulp vitality.
 Depends upon
- depth
-direction
of the fracture
 Tooth should be stabilised and splinted
immediately with an orthodontic wire
When part of a tooth breaks away-
appropriate restoration

Crack at the base of the buccal or lingual cusp

which does not move or break away and no
pulpal involvement-crowning of the tooth
 Crack over the roof of pulp chamber and coronal pulp
involved-root canal treatment

 Fracture line at base of the pulp chamber after removal

of the coronal pulp-extraction
•Vitality tests are necessary to determine the extent of pulpal
damage.
•The pulp may not respond to tests initially, but positive
responses can return weeks or months later.
•Teeth that respond negatively immediately after the trauma
tend to remain vital.
•At 3 months, there is a high correlation between teeth testing
vital and those remaining vital indefinitely.
•Proper prognosis assessment prior to any dental treatment is
imperative, but is often difficult in cases of cracked teeth.
•Because of the questionable long-term success from treating
cases of suspected or known fractures,the clinician should be
cautious in the decision to continue with treatment and should
avoid treating cases of definitive split roots
 References

•Endodontics and Dental Traumatology-An Overview of

Modern Endodontics-Paul Abbott

•Incomplete tooth fracture — proposal for a new

definition. S. G. S. Ellis, BRITISH DENTAL JOURNAL
VOLUME 190 NO. 8 APRIL 28 2001.

• Guideline on Management of Acute Dental Trauma

AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
REFERENCE MANUAL V 34 / NO 6
•Cracked Tooth: A Report of Two Cases and Role of
Cone Beam Computed Tomography in diagnosis. CASE
REPORTS IN DENTISTRY Volume 2012 (2012), Article ID
525364,

•Diagnosis of cracked tooth syndrome J Pharm

Bioallied Sci. 2012 Aug; 4(Suppl 2): S242–S244
Thank you