Dental Traumatology 2006; doi: 10.1111/j.1600-9657.2006.00347.

x Copyright Ó Blackwell Munksgaard 2006

All rights reserved
DENTAL TRAUMATOLOGY

Analysis of 154 cases of teeth with cracks

Roh BD, Lee YE. Analysis of 154 cases of teeth with cracks. Byoung-Duck Roh, Young-Eun Lee
Ó Blackwell Munksgaard, 2006. Department of Conservative Dentistry, Dental College,
Yonsei University, Seoul, Korea
Abstract – It is well known that cracked teeth occur most
frequently in the mandibular molars with large or poor restora-
tions, in those over 50 years of age. However, with increasing
knowledge and experience with cracks of teeth, cracks appear to be
found frequently in intact teeth without restorations. The aim of
this study is to analyze the cases of tooth cracks in a dental hospital
in a year, and to find out the characteristic features of cracks of
teeth. For 1 year, each tooth that were identified as a cracked tooth
was recorded and analyzed in terms of the classification of cavity
and restorative material, the nature of opposing tooth, the location
in the arch, the age and gender, and the clinical signs and
symptoms, and treatment result. Cracked teeth were observed
most frequently in the teeth with no restorations (60.4%) and with
class I restorations (29.2%). The most prevalent age was in those
over 40 years of age (31.2% in their 40s, 26.6% in their 50s) and
the prevalence was similar in men (53.9%) and women (46.1%).
Cracked teeth were found most frequently in the maxillary molars
(33.8% in first molar, 23.4% in second molar) than in the Key words: cracked tooth syndrome; restoration;
mandibular molars (20.1% in first molar, 16.2% in second molar). molar; age distribution; stress; mechanical; tooth
96.1% of the cracked teeth responded to the bite test, and 81.1% fracture
of the cracked teeth were observed in the mesiodistal direction. Byoung D. Roh, Conservative Dentistry, Dental
The prevalence of cracked tooth was highest in the intact teeth College, Yonsei University, 134 Shinchon-Dong,
Seodaemoon-Gu, Seoul, Korea
with no restoration, in maxillary molars, and in those over Tel.: +82 2 361 8716
40 years of age. When examining a intact maxillary posterior tooth Fax: +82 2 313 7575
that is sensitive to a bite and thermal change, crack in the e-mail: operatys16@yumc.yonsei.ac.kr
mesiodistal direction need to be considered one of the causes. Accepted November 13, 2003

In 1964, Cameron (1) used the term ‘cracked tooth loss of a marginal ridge in a class II restoration was
syndrome’ in his report to describe the uncommon considered to be one of the major causes of tooth
clinical situations characterized by discomfort to weakening, and a properly small class I restoration
chewing pressure and abnormal sensitivity to ther- was considered to have little effect on the crack of
mal changes in otherwise normal teeth. As a reason the tooth.
for these unusual symptoms, incomplete tooth Other reports about the incidence and prevalence
fracture was suggested and it was termed as ‘cracked of incomplete tooth fractures have since been
tooth syndrome’. According to him (2), cracks were published, and most authors agreed that cracked
prevalent in females (66.7%), over 50 years of age teeth were significantly associated with intracoronal
(58%), in the mandibular second molar (37.2%) restorations and were prevalent in mandibular
followed by the mandibular first molar (29.4%), and molars (2–12). The most commonly identified
five teeth had no restoration, and 28 teeth had etiologic factor was the design of cavity prepara-
occlusal class I restoration from 50 cracked teeth. tions. Large restorations, improper and overzealous
He reported that there was a direct relationship preparations, the inappropriate use of pins, and
between the size of the restoration and the occur- marginal ridge restorations were mentioned as
rence of a crack of tooth. Teeth with a class II factors responsible for cracks of teeth, although
restoration were cracked approximately three times other factors, such as sudden biting of hard
more than the teeth with a class I restoration. The substances, the excessive contact of a posterior

118 Dental Traumatology 2006; 22: 118–123

 Analysis of 154 cases of teeth with cracks

tooth during eccentric jaw movement, wear, brux- probing, the nature of occluding tooth, chewing
ism, malocclusion, steep cusp inclines and/or deep habit and favorite food type, and the treatment
grooves in the occlusal morphology, and thermal result were recorded.
cycling were mentioned as the causes of the cracks In 1 year, 154 teeth from 141 patients were
of teeth (1, 5, 8, 10, 13–16). diagnosed as cracked tooth. The data of these teeth
Cracks in intact teeth are still considered to an were collected and analyzed according to the
unusual and embarrassing situation. Only a few restorative material and the classification of the
cases of cracks in intact teeth with no restoration restoration, clinical signs and symptoms, age and
have been reported, which occurred bilaterally in gender, the location of the tooth in the jaw, the
intact maxillary first molars (17, 18). They suggested direction of the crack line, and the treatment result.
that these were caused by occlusal traumas such as a
steep cusp inclination and too heavy bite forces.
Results
Although cracks in intact teeth are still considered
to be unusual, cracks in teeth with no restoration From the data of 154 teeth, the following results
appear more frequently in dental offices these days, were found (Tables 1–6).
and the location of cracked teeth in the mouth Ninety-three cracked teeth were intact teeth with
seems to vary. This may partly be because of no restorations (60.4%), and 61 with restorations
advances in the diagnosis of crack of tooth by (39.6%). From the 61 restored teeth, 45 teeth
increasing knowledge and experiences about the (29.2%) had a class I restoration and 14 teeth (9.1%)
nature of crack, and partly because of the changes in had class II restorations. Regarding the type of
the chewing patterns. restorative materials, there were almost equal num-
The aim of this study is to analyze the cracks of bers of amalgam restorations and gold inlay resto-
teeth encountered in one dental hospital in a year, rations regardless of the classification of restorations
and to find out the characteristic features of cracks and the gender of the subjects. 120 cracked teeth
of teeth. were occluded with intact teeth with no restorations
(77.9%).
Cracked tooth was found most frequently in the
Materials and methods
upper first molar (33.8%). The upper second
All the teeth, which were suspected as cracked teeth molar was the next (23.4%), and lower first molar
in department of conservative dentistry in Yonsei (20.1%) and lower second molar (16.2%) followed.
dental hospital during 1 year, were examined The prevalence of crack in the premolar was
thoroughly. The identification of a crack was carried 4.5% in the maxilla, and 2% in the mandible. In
out using transillumination, the application of dye, males 53.9% of cracked teeth were found, and
or a bite test with a tooth slooth or a roll of a rubber cracks were most frequently found at the age of
dam. The teeth that were diagnosed as cracked 40s and 50s. At the age 20s, 12.3% of cracks were
teeth were double-checked during the treatment found, while no cracks were found under the age
sessions. of 20.
Once a crack had been identified, the subjects’ The most common direction of the crack was the
age, gender, tooth number, restorative material and mesiodistal direction in both jaws (108 teeth,
cavity classification, pulp vitality, mobility of the 70.1%). The buccolingual direction was found in
tooth, rate of wear, direction of crack, result of 29 teeth (18.8%) and 17 teeth (11%) cracked in both
percussion and bite tests, depth of periodontal directions.

Table 1. The relationships between the crack and the type of restorative material and opposing tooth
Variables Cracked tooth [n (%)] Opposing tooth [n (%)]
Sex Male Female Total N G P A C I Total
No restoration (N) 54 (35.1) 39 (25.3) 93 (60.4) 84 7 1 1 93
Gold crown (G) 1 (0.6) 1 (0.6) 2 (1.3) 2 2
Classification Cl I Cl II Cl I Cl II
Amalgam (A) 9 2 10 3 24 (15.6) 14 4 6 24
Composite (C) 1 0 1 0 2 (1.3) 2 2
Gold inlay (I) 9 2 8 3 22 (14.3) 10 4 1 7 22
Temporary filling 3 2 4 2 11 (7.1) 10 1 11
Sum of restorations 22 6 23 8 59 (38.3)
Total 83 (53.9) 71 (46.1) 154 (100) 120 (77.9) 17 (11) 2 (3.9) 6 (3.9) 1 (0.7) 8 (5.2) 154 (100)
N, no restoration; G, gold crown; P, porcelain; A, amalgam; C, composite resin; I, gold inlay.

Dental Traumatology 2006; 22: 118–123 119

Roh & Lee

Table 2. Distribution of cracks according to the location of the teeth

Type of teeth Male Female Total [n (%)] Type of teeth Male Female Total [n (%)]
Max. 1st PM 3 1 4 (2.6) Mn. 1st PM 1 0 1 (0.7)
Max. 2nd PM 2 1 3 (1.9) Mn. 2nd PM 1 1 2 (1.3)
Max. 1st M 25 27 52 (33.8) Mn. 1st M 15 16 31 (20.1)
Max. 2nd M 18 18 36 (23.4) Mn. 2nd M 18 7 25 (16.2)
Total 48 47 95 (61.7) Total 35 24 59 (38.3)

Table 3. The relationship between age, gender, and cracked tooth Table 5. Clinical sign and symptom of a cracked tooth
Age (year) Male Female Total % Negative Mild Moderate Severe
20–29 12 7 19 12.3 Pocket depth (0–3 mm) (3–6 mm) (6–9 mm) (9–12 mm)
30–39 19 11 30 19.5 (periodontal) 64 45 32 13
40–49 21 27 48 31.2 Wear facet (occlusal) 148 0 0 6
50–59 20 21 41 26.6 Bite test 6 138 7 3
60–69 8 2 10 6.5 Percussion test 66 71 17 0
>70 3 3 6 3.9 Pulp vitality test (cold) 4 81 53 16
Total [n (%)] 83 (53.9) 71 (46.1) 154 100

Table 6. Treatment of cracked tooth

Almost of the cracked teeth showed responses to Treatment Number of the teeth (%)
the bite test (96.1%). Eighty-eight teeth were
percussion-positive (57.1%) and 69 teeth showed Crown 65 (42.2)
Crown + root canal treatment 61 (39.6)
moderate to severe sensitivity to the ice test (44.8%). Temporary crown + root canal treatment + crown 2 (1.3)
Forty-five teeth (29.2%) had a deep pocket (over Band + root canal treatment + crown 2 (1.3)
6 mm), and another 45 teeth had pocket of the Resin filling 3 (2.0)
middle depth (3–6 mm) while 64 teeth (41.6%) Extraction 21 (13.6)
showed normal periodontal tissues. Severe occlusal
wear facets were observed in six teeth.
Sixty-five teeth were covered with a full veneer posterior teeth including cracks and complete cuspal
crown without a root canal treatment (42.2%), and fractures, and reported that the majority of fractures
the other 65 teeth were restored with a full veneer did not involve the pulp but ended above the
crown after the root canal treatment. Twenty-one epithelial attachment. Because the crack did not
teeth had to be extracted (13.6%). involve the pulp, there was little pain initially and
the history of mild pain would often had been lasted
12–18 months before the patient visited dental
Discussion
clinic. If the crack developed to a complete cuspal
In a tooth with a large restoration, the crack tends to fracture, the pain would disappear.
be more superficial because the occlusal stress On the contrary, the cracks in the teeth with no
concentrates in the tooth-restoration interface. restorations would occur more centrally and closer
Consequently it may produce mild or no symptoms. to the dental pulp, which might produce more
In one report, in which the cracks of teeth were severe symptoms. One of the highest prevalence
found more frequently in restored teeth, two teeth reports about cracks in intact natural teeth were
were endodontically treated and one tooth was reported by Hiatt (8). In his reports, 35% of cracks
extracted out of 62 cracked teeth (9). Snyder (19) occurred in teeth with no restorations, 39% in class
and Lagouvrdos et al. (10) examined the fractured I restorations, and 26% in class II restorations. As

Table 4. Direction of the crack line

M-D [n (%)] B-L [n (%)] M-D & B-L [n (%)]
Male Female Total Male Female Total Male Female Total
Maxilla 32 39 71(74.7%) 9 7 16(16.8%) 7 1 8(8.5%)
Mandible 23 14 37(62.7%) 9 4 13(22.0%) 3 6 9(15.3%)
Total 55 53 108(70.1%) 18 11 29(18.8%) 10 7 17(11%)
M-D, Mesiodistal direction; B-L, Buccolingual direction.

120 Dental Traumatology 2006; 22: 118–123

 Analysis of 154 cases of teeth with cracks

the causes of cracked teeth, he suggested the was already movable equally, and it usually involves
occlusal habits and the wedging effect of the cusp- the infrabony structures. A vertical root fracture is
fossa relationship. According to him, an internal defined as a longitudinal fracture confined to the
structural weakness might exist at the calcification root. It usually begins on the internal wall of root
sites that had failed to coalesce between the cusps. canal and extends outward to the root surface. A
These weak areas were noted in pits, fissures, crack is defined as an incomplete fracture of a vital
grooves and lamella. When cusp-fossa relation- tooth involving the dentin and possibly the dental
ships were exerted in these weak areas, internal pulp, while a cusp fracture is a tooth fracture caused
stresses were induced in these areas. Gradually the by the lack of cusp support as a result of a weakened
stresses were concentrated at the interproximal marginal ridge. The main characteristics of a cusp
surfaces and these could lead mesiodistal crack. fracture are that it generally involved one cusp and
Ehrmann and Tyas (20) reported the crack usually usually terminated parallel to the gingival margin or
originated more centrally than a complete cusp slightly subgingivally.
fracture and extended into the dentin without a loss Regardless of these classifications, several reports
of the tooth structure. Centrally located cracks have used the term ‘tooth fracture’ without discrim-
appear to follow the lines of the dentinal tubules and inating between a complete and an incomplete
lead toward the pulp, which might result in a split tooth fracture. Some authors included the complete
tooth. and incomplete fracture in their studies under the
In this study, 60.4% of cracks occurred in intact broad term ‘tooth fracture’ (7, 15, 19, 21, 25, 26),
teeth with no restoration and 29.2% in class I while others excluded incomplete fracture or com-
restorations. This means that 89.6% of cracks of plete fracture in order to prevent contamination of
teeth occurred without serious weakening of the their results (3, 5, 6, 10, 27).
tooth structure, and 42.2% of these cracked teeth Similarly, a ‘cusp fracture’ could be used to
were treated endodontically and 13.6% had to be describe both the incomplete and complete cusp
extracted. fracture. And it seems to be impossible to distinguish
Therefore, the cracks in intact teeth with no the crack from incomplete cusp fracture in early
restoration and largely restored teeth should be to stage. The differences between them were the
be regarded as different ones, even though they weakened marginal ridge and the symptoms that
were similar in the early stage. Many papers on could not be trusted. New categorization scheme
‘cracked tooth syndrome’ with large intracoronal may be necessary to clarify these problems.
restorations or cavity preparations (1–12) might be Ellis et al. (25) examined 271 tooth fractures, and
the results of incomplete cusp fractures instead of reported that 97% were complete and 3% were
cracked teeth. incomplete fractures. They examined the relation-
There have been a few categorization schemes ship between the patients’ age and tooth fracture.
suggested for tooth fractures. Talim and Gohil (21) The median age of the patients with 263 complete
categorized the tooth fracture mainly according to fractures was 21, whereas that of those with
the depth of the tooth fracture. Their second incomplete fractures was 34 years. They concluded
category was whether the fracture was horizontal that the age distribution of those with complete and
or vertical, and the third category was whether it incomplete fractures was significantly different, and
was complete or incomplete. incomplete fracture was caused by an age-related
Another proposal for classification of tooth frac- tooth fatigue and minor traumas of cumulative
tures was to categorize the tooth fracture simply into effects.
a complete tooth fracture and an incomplete In this study, 57.2% of cracks were found in
fracture (14, 22, 23). The criterion was whether maxillary first molars. However, many authors
there was loss of the tooth structure, or whether the reported that the mandibular molars were the most
fractured segment was independently movable or common area of cracks and complete cusp fractures
not. Because it was quite simple and was able to (1–12). Ehrmann and Tyas (20) suggested that the
include the broad variations of tooth fractures, this lingual cusp of upper molars could act as a plunger
classification was used widely. However, it was too that was inducing structural fatigue in their man-
simple to express the clinical and pathological dibular antagonists, and the lower molars had
characteristics of tooth fracture properly. central fossa deeper than the upper molars, while
Recently, Simon (24) categorized a tooth fracture the oblique ridge in the upper molar provided the
into five major classes; craze line, cuspal fracture, strength needed to resist cracks.
cracked tooth, split tooth and vertical root It was known that Korean had more lingually
fracture. The craze line is a fracture line confined tilted lower molars (28), and smaller and shorter
to the coronal enamel without signs and symptoms. teeth than Caucasian (29). The lingually tilted lower
Split tooth means a complete tooth fracture, which molars might be able to reverse the situations. The

Dental Traumatology 2006; 22: 118–123 121

Roh & Lee

buccal cusps of the lingually tilted lower molars 4 The most common direction of a crack was in the
could act as plunger cusps to the maxillary molars. mesiodistal directions (81.1%).
Smaller amounts of dentin and the surface area of 5 Cracked teeth were occluded with natural teeth
the roots absorbed less occlusal stress and trans- with no restorations (77.9%) and 3.9% of occlu-
ferred less occlusal forces to the alveolar bone. Also, ding teeth to the cracked teeth showed severe
the prevalence of the C-shaped root canal in the occlusal wear facets.
mandibular second molar is higher in Asian than in 6 The most reliable clinical test result was the bite
Caucasian (30, 31). C-shaped canal joined the test (96.1%).
mesial and distal root, which may provide the 7 Cracked teeth were treated with crowns (84.4%)
additional resistance to the lower second molar. and in half of these cases root canal treatment
In this study, 89.6% of cracks were found in were performed (42.2%).
teeth with no restorations or class I restorations. In the limit of this study, it was found that cracks
The one of possible explanations for this high could occur frequently in intact natural teeth that
percentage of cracks in natural intact teeth was are occluded with natural teeth. So when examining
that general practitioner usually referred their the intact teeth that are sensitive to bite test and
patients to a dental hospital, whose teeth were thermal changes, the possibility of cracks must be
symptomatic but the causes of the symptoms were checked carefully.
not easily identified. In dental hospitals, endodon-
tists usually examined the teeth. Therefore, there Acknowledgement – This work was supported in part
might be a high frequency of cracked teeth in by Yonsei University of Dental College Research
natural teeth and maxillary molars. Another poss- Fund.
ible explanation for high prevalence of crack in
intact teeth was the favor of hot food in Korean.
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