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Journal of Dental Health, Oral Disorders & Therapy
Longitudinal Tooth Fractures Review
Case Series
Case 1
Introduction
Identenfication of tooth fractures is a key point for managment
and treatment success. Therefore, such knowledge is necessary
for general dentists and endodontists.
a. 60 years old male patient.
b. Area of interest: tooth #26.
Chief complaint
1. I have pain to cold drinks. Also, I can’t chew on that tooth (he
pointed to #26).
2. The pain started 2 weeks ago but even before that the patient
experienced some discomfort upon chewing (Figure 1).
Volume 7 Issue 1 - 2017
Department of Restorative Dental Science, King Saud
University, Saudi Arabia
*Corresponding author: Abdulla M Riyahi, Department of
Restorative Dental Science, Assistant Professor, College of
Dentistry, King Saud University, Saudi Arabia,
Email:
Received: March 28, 2016 | Published: April 13, 2017
Medical history
1. Non-contributory medical history.
2. Medications: None.
3. Major Surgeries: None.
4. Allergies: None.
5. None smoker patient.
6. ASA I (Figure 2).
Dental history
1. Bruxism: The pt is using night guard (since 4 years).
2. The pt. had history of loosing teeth due to cracks.
3. Tooth brushing: 2/day.
Extra & intra-oral exam
Figure 1
1. E/O: Symmetrical face, no head & neck lymphadenopathy,
no TMJ clicking, no limited mouth opening.
2. I/O: Occ wear.
Figure 2
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J Dent Health Oral Disord Ther 2017, 7(1): 00227
Copyright:
©2017 Riyahi
Longitudinal Tooth Fractures Review
2/11
Chipped enamel (Q3) (Figure 3-16).
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Copyright:
©2017 Riyahi
Longitudinal Tooth Fractures Review
Figure 9
Figure 10
Figure 11
Figure 12
Figure 13
Figure 14
3/11
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Copyright:
©2017 Riyahi
Longitudinal Tooth Fractures Review
Figure 15
Radiographic fining
1. Tooth # 15: Periapical RL.
2. RL in the coronal area (due to the fractured cusp).
Diagnosis
1. Tooth #26: Symptomatic irreversible pulpitis with
symptomatic apical periodontits (Crack line can be seen
clinically).
2. Tooth #15: Necrotic pulp with asymptomatic apical
periodontitis (fractured cusp).
Treatment
Tooth #15: was referred to the pros and them thought is not
restorable.
4/11
Figure 16
Clinical Procedure: 1st Visit #26
1. LA: 1 carp. of 1.8 ml lidocaine 2% (1:100,000 epi) bucc
infiltration.
2. Rubber dam isolation.
3. Access opening.
4. Initial instrumentation.
5. Ca(OH)2 application.
6. Cotton and Cavit.
7. Tooth was taken out of occlusion.
Treatment plan for #26
Prognosis: uncertin (Figure 17).
Figure 17
Figure 18
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Copyright:
©2017 Riyahi
Longitudinal Tooth Fractures Review
Figure 19
5/11
Figure 20
2nd Visit
a. No more pain to cold.
b. Pain to chewing sill there.
c. The two segments can be separated with the crack extending
to the temporary restoration.
d. The smaller segment couldn’t be removed.
e. The case was referred to perio for evaluation of the
possibility of crown lengthening after segment removal.
f. The fracture was bone level. The tooth has hapless prognosis.
g. Extraction (Figure 21,22).
Cusp fracture (below CEJ & bone level) (Figure 23).
Figure 22
Figure 21
Figure 23
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Copyright:
©2017 Riyahi
Longitudinal Tooth Fractures Review
6/11
Case 2
Introduction
1. 54 years old male patient
2. Area of interest: Tooth # 34
Chief complaint
I have pain and swelling on that tooth (pt pointed to #34)
(Figure 24).
Figure 25
Figure 24
Figure 26
History of chief complaint
1. 4 months ago the pt felt some discomfort upon chewing on
#34.
2. Pain and swelling started 1 month ago.
3. The patient took amoxicillin for the last 2 weeks.
Medical History
Noncontributory medical history.
Dental history
Bruxism, The pt has a night guard but he doesn’t use it.
Extra & Intra-oral exam
a. E/O: Symmetrical face, no head & neck lymphadinopathy, no
TMJ clicking, no limited mouth opening.
b. I/O: Occ wear (Figure 25-30).
Figure 27
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Copyright:
©2017 Riyahi
Longitudinal Tooth Fractures Review
7/11
b. PFM crown
c. Bear shape Periradicular RL
d. Black lines in the apical third (sign of VRF).
Implant replacing tooth #36.
Diagnosis
i. Tooth #35
a. Previously treated with symptomatic apical periodontitis.
b. VRF.
Figure 28
c. The pt chose not to have exploratory surgery done.
Treatment
Prognosis: Hopeless (Figure 31).
Figure 31
Outline (Figure 32).
Figure 29
Figure 32
Fractured cusp
1. It is a complete or incomplete fracture initiated from the
crown of the tooth and extending subgingivally, usually
directed both mesio- distally and facio-lingually.
2. The fracture usually involves at least two aspects of the cusp
by crossing the marginal ridge and also extending down a
facial or lingual groove.
Figure 30
Radiographic fining
I. Tooth #34
a. RCT
b. Gold crown
a. Fractured cusp direction (Figure 33).
Figure 33
b. Crack origin (Figure 34).
II. Tooth # 35
a. RCT
Figure 34
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Copyright:
©2017 Riyahi
Longitudinal Tooth Fractures Review
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c. Fractured cusp etiology (Figure 35).
Figure 38
Cracked Tooth
An incomplete fracture initiated from the crown and extending
subgingivally, usually directed mesio-distally (Figure 39).
Figure 35
Fractured Cusp Diagnosis (Figure 36)
a. Tooth Slooth: Often the pain is more distinct upon
masticatory release.
b. Usually, pulp tests indicate vitality.
Figure 39
Cracked tooth clinical features
Figure 36
Fractured Cusp Treatment (Figure 37)
The fracture may or may not include the pulp. The more
centered the fracture, the greater the chance of current or future
pulp exposure (Figure 40).
a. The cusp is removed and the tooth restored as appropriate.
b. Only or full crown extending below or to the fracture margin.
Figure 37
Fractured Cusp prognosis
Usually good (Figure 38).
Figure 40
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Copyright:
©2017 Riyahi
Longitudinal Tooth Fractures Review
Cracked tooth aetiologies
a. Cracked teeth are often found in patients who chew hard,
brittle substances (ice, unpopped popcorn kernels, hard
candy, and so on).
b. These patients may have prominent masticatory muscles.
Cracked tooth clinical finding
a. Often cracked teeth manifest as the so-called cracked tooth
syndrome.
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Split tooth
a. A complete fracture initiated from the crown and extending
subgingivally, usually directed mesio-distally through both
of the marginal ridges and through the proximal surfaces.
b. A split tooth is the end result of a cracked tooth (Figure
41,42).
b. This syndrome is characterized by acute pain on mastication
(pressure or release).
c. The pulp is usually responsive (vital) but may be nonresponsive (necrosis).
d. Periapical tests also vary but usually pain is not elicited with
percussion or palpation if the pulp is vital.
Cracked tooth syndrome?
a. Cracked teeth may present with a variety of symptoms
ranging from slight to very severe spontaneous pain
consistent with irreversible pulpitis, pulp necrosis, or apical
periodontitis.
b. Even an acute apical abscess, with or without swelling
or a draining sinus tract, may be present if the pulp has
undergone necrosis.
c. In other words, once the fracture has extended to and
exposed the pulp, severe pulp and/or periapical pathosis
will likely be present.
d. This explains the variation in signs and symptoms &
therefore the term ‘syndrome’ should not be used.
Cracked tooth diagnosis
1. Inspection
2. Staining
3. Transillumination
4. Restorations removal
5. Surgical microscope
6. Wedging forces are used to determine if the tooth segments
are separable.
7. Biting test.
8. Periodontal probing.
Cracked tooth treatment
a. Only or crown.
b. In case of deep crack extraction.
Figure 41
Vertical root fracture
a. A complete or incomplete fracture initiated from the root at
any level, usually directed facio-lingually.
b. The fracture is located in the root portion of the tooth only
and may extend coronally toward the cervical periodontal
attachment.
Pathogenesis
It results from wedging forces within the canal. These excessive
forces exceed the binding strength of root dentin, causing fatigue
and fracture (Figure 43).
Etiologies
a. Excessive dentin removal during canal instrumentation.
b. Post placement (cementation) and designed (too long or too
wide).
c. Lateral and vertical Condensation.
d. Occlusal forces exerted on the post after cementation.
e. Roots that are curved and are deep facially & lingually but
narrow mesially & distally are particularly prone to fracture.
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Copyright:
©2017 Riyahi 10/11
Longitudinal Tooth Fractures Review
Figure 42
f. Examples are mandibular incisors and premolars, maxillary
second premolars, mesio-buccal roots of maxillary molars,
and mesial and distal roots of mandibular molars.
Diagnosis
3. The post-design least likely to cause fracture dentin is
the flexible (including carbon-fiber) or parallel- sided
preformed post [3].
a. Often asymptomatic.
b. Localized swelling may be present.
c. Deep narrow pocket.
d. Radiographic findings
e. Lesion extending over the apex and along one root
f. surface (J-shaped or halo pattern)
g. Deep, localized, vertical bone loss.
h. Visible separations of fractured root segments in (only a
small percentage of teeth).
Figure 43
i. CBCT.
j. Flap reflection (High magnification, illumination and
staining with dye is Helpful).
Prognosis
a. Hopeless.
b. Treatment is removal of the fractured root or extraction of
the tooth (Figure 44).
Prevention of VRF
1. Avoid excessive removal of intraradicular dentin & minimize
wedging forces [1].
2. More flexible and less tapered finger spreaders are preferred
over hand-type spreaders [2].
Figure 44
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227
Longitudinal Tooth Fractures Review
References
1. Eric Rivera, Richard W (2007) Longitudinal tooth fractures: findings
that contribute to complex endodontic diagnoses. Endodontic
Topics 16(1): 82-111.
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2. Dang DA, Walton RE (1989) Vertical root fracture and root distortion:
effect of spreader design J Endod 15(7): 294-301.
3. Sirimai S, Douglas, Steeven (1999) J Prosthet Dent 1999: 81: 262269.
Citation: Riyahi AM (2017) Longitudinal Tooth Fractures Review. J Dent Health Oral Disord Ther 7(1): 00227. DOI: 10.15406/jdhodt.2017.07.00227