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MACIEJ ZAROW
INDIRECT POSTERIORS - CASES
FABIO GORNI INTERVIEWS
CLIFFORD RUDDLE

CRACKED TOOTH: DIAGNOSIS AND ADHESIVE

TREATMENT
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Cracks in teeth may occur in both the horizontal and vertical directions, involving the crown and/or
root. The etiology is generally a result of occlusal forces and iatrogenic procedures.
Crown and crown-root fractures are usually incomplete fractures commencing in the crown of the
posterior teeth and extending towards the cemento-enamel junction, or apically into the root. At first,
this may become apparent in the form of a fine, superficial fracture line, and in later stages it may
develop into a continuous crack, eventually causing the tooth to split.
Vertical root fractures are longitudinally orientated fractures of the root that extend from the root
canal to the periodontium. Vertical root fractures most commonly occur in root canal treated teeth
and among patients over 40 years old.

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During a routine clinical check up, the dentist should pay attention to crack lines, especially in the
posterior region. A cracked tooth is often detected too late, when a patient visits with symptoms of
pain.
Classification of fractures.
The term longitudinal fracture typically describes fractures that extend vertically over time. These
linear fractures tend to grow and change, as opposed to those resulting from impact trauma.
In dental literature there is a lot of misunderstanding about the terminology of fractures. The
American Society of Endodontics divided longitudinal tooth fractures into five groups.
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The first four groups originate in the crown of the tooth, and the last in the root. There are distinct
delineations, as fractured cusps and vertical root fractures imply a complete or incomplete break of
the tooth; craze lines and cracked teeth are only incomplete breaks in teeth; and split teeth are only
complete breaks in teeth.
Group I: Craze lines
Group II: Fractured Cusp
Group III: Cracked Tooth
Group IV: Split Tooth
Group V: Vertical Root Fracture:
Case ReportMaxillary right upper second molar with a clear crack line. The cold vitality test with
carbon dioxide snow (CO2 - Odontotest, Fricar A.G., Zurich, Switzerland) showed sensitive reaction of
the pulp typical for the vital pulp, and the tooth was not sensitive during percussion test. The
radiograph did not show an inflammatory lesion (Fig 2). A 43-year-old male patient presented in the
dental office with typical symptoms of a cracked maxillary right upper second molar. The following
clinical symptoms were recorded during patient anamnesis:? - increased pain when consuming cold
food or drink?- sharp pain when biting, as the applied occlusal force increased?- pain on release of
pressure when eating fibrous foods ?- pain increased during the act of tooth grindin. The clinical

examination with magnification (Zeiss loops 4.0) showed a clear crack line extending through the
distal marginal ridge (Fig 1).

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Fig 1.?Maxillary right upper second molar with a clear crack line. ??The cold vitality test with carbon
dioxide snow (CO2 - Odontotest, Fricar A.G., Zurich, Switzerland) showed sensitive reaction of the
pulp typical for the vital pulp, and the tooth was not sensitive during percussion test. The radiograph
did not show an inflammatory lesion (Fig 2).

Walter Devoto
Dr. Walter Devoto Born in
Chiavari on 29/03/1965
graduated in Dentistry in 1991
at Genova University.

Angelo Putignano
M.D. degree and D.D.S. post
graduate certificate from
University of Ancona-Italy.

FOUNDERS ENDO

Pio Bertani
Pio Bertani is a full member of
the prestigious association...

Fabio Gorni
Fabio Gorni is an active
member of the Italian Society
of Endodontics and the Italian
Academy...

MEMBERS
Monaldo Saracinelli
Ive been a student of prof.
Fabio Toffenetti and
Riccardo Garberoglio.

Jordi Manauta
Was born in Mexico City,
where he graduated cum
laude. in dentistry from
UNITEC.

Gaetano Paolone
My passion is aesthetic
direct and indirect
adhesive dentistry in
anterior and posterior
teeth.

Daniele Rondoni
Born in Savona in 1961
where he lives and has

Fig 2. ?The radiagraph of the tooth 17 ?The purpose of the treatment was to immediately stop the
crack extension obtaining adhesive composite indirect restoration with total cusp coverage. ??At the
same appointment, the tooth was prepared for indirect composite onlay with complete cusp
coverage, using the burs from Indirect Style (Fig 3).?

worked in his own

laboratory since...

Vincenzo Musella
Vincenzo Musella
graduated in dental
technician. Proud friend
and student of...

Giuseppe Marchetti
Giuseppe Marchetti was
born in Parma (Italy) in
October of 1972 and
graduated from...

Simone Grandini
Chair of Endodontics and
Restorative Dentistry,
University of Siena, Italy.

Giovanna Orsini
Giovanna Orsini is a well
known researcher in Italy
and internationally.

Paulo Monteiro
My passion for esthetic
dentistry began when I
attended the last year...

Louis Hardan
Head of Restorative and
Esthetic department in
Saint-Joseph University
in...

Fig 3.?The set of burs for indirect restorations (Indirect Style).??? In the first stage of preparation,
the depth grooves (Fig 4 a, b) were made on the occlusal surface in order to ensure sufficient space
for the composite material (2.0 mm).?

Patrizia Lucchi
Patrizia Lucchi Graduated
in Dentistry cum Laude in
1995 at the University of
Verona

Anna Salat
Dr Anna Salat graduated
with a degree in dentistry
from the International
University of Catalonia

Giulio Pavolucci
After graduation magna
cum laude in Dentistry, I
started focusing my daily
work on...

Marcos Vargas
Dr. Marcos Vargas
attended Cayetano
Heredia University School
of Dentistry in Lima...

Stefan Koubi
Dr. Koubi graduated from
University of Marseille
where he...

Engin Taviloglu
Dr. Taviloglu graduated
from ?stanbul University
School of Dentistry in...

Fig 4 a The depth grooves on the occlusal surface of the tooth 17?

Dimitar Filtchev
Co-founder of the Laser
Dental Center and the
Implant...

Angie Segatto
My commitment to arts has
determined my
specialisation.

Kilian Molina
Kilian is required as a
regular lecturer in indirect
restorative...

Gregory Camaleonte
I was born in 1980 in
Marseille-France and i have
graduated in 2006 from...

Caroline Werkhoven
Caroline Werkhoven
graduated in 2002 at
ACTA, the dental faculty in
Amsterdam..

Ajay Juneja
Ajay Juneja finished his
BDS in the year 1995...

Fig 4b ?The depth grooves on the occlusal surface of the tooth 17

Carlos Fernndez
Villares
Member of SEPES Spanish
Soc...

?
Then the occlusal surface was leveled and the mesio-proximal contact point was released. The
demineralized dentin tissues present inside the disto-occlusal crack line (Fig 5) were carefully
removed (Fig 6), and the dentin was immediately sealed with bonding agent.

Sulivan Leite
Sulivan Leite graduated
from the Ribeirao...

Maciej Zarow
Author of book edited by
Quintessence: EndoProsthodontics: guidelines
for clinical practice ...

Dan Lazar
Dan Lazar, graduated from
the Faculty of Dentistry in
2005 in Cluj-Napoca...

Murad Akhundov
Dr. Murad Akhundov
graduated from the
Faculty of Dentistry in
Baku...

Janos Grosz
Graduated summa cum
laude in 2006 from the
University of Szeged,
Faculty of Dentistry,
Hungary...

Fig 5 ?At the bottom of the crack line, demineralized dentin was visible.

MEMBERS ENDO
Simone Grandini
Chair of Endodontics and
Restorative Dentistry,
University of Siena, Italy.

Louis Hardan
Head of Restorative and
Esthetic department in
Saint-Joseph University
in...

Filippo Cardinali
Graduate in Dentistry and
Dental Prostheses at the
University of Ancona in
1992. Active Member of...

Riccardo Tonini
He is active member of the
Italian Academy of
microscopic Dentistry and
Active member of...

Paolo Generali
Doctor Generali was
graduated from Pavia
University in the year...

Calogero Bugea
Graduate in Dentistry,
Certificate in Oral Surgery.
Active Member of the
International
Piezosurgery...

Clifford Ruddle
Internationally recognized
as a leading expert in all
aspects of clinical
endodontics, Dr. Ruddle is
acclaimed for...

Pierre Machtou
Pierre Machtou was the
first scientific director and
general secretary of the
French Endodontic
society...

Marga Ree
Primary author of several
articles published in
national and international
journals and has ...

Marco Martignoni
Marco Martignoni leads a
private clinic in Rome Italy
and dedicates his practice
mainly to endodontics,
pre-prosthetic...

Massimo Giovarruscio
Massimo Giovarruscio
works in Rome, Bristol and
London, specialising in
Endodontic Treatment
and...

Fig 6? The situation immediately after removal of demineralized dentin. The deepest part of the
cavity was restored with fiber reinforced composite resin (Ever X Posterior, GC) in order to level the
bottom of the preparation (Fig 7).

Fig 7 . ?The bottom of the crack line covered with fiber reinforced composite resin (Ever X Posterior,
GC)???The aim of the dentin sealing with fiber composite resin material was also to stop the crack
propagation, by means of short fibers incorporated in the material sub-structure.?An impression was
taken with polyether precision impression paste (Impregum, 3 M ESPE) and sent to the laboratory in
order to manufacture an indirect composite restoration. ?One week later the composite onlay
(Enamel Plus, Micerium) was checked on the model and in the mouth of the patient, with regards to
the color, marginal adaptation and contact point (Fig 8 a).

Fig 8 a?Indirect composite onlay fabricated in the laboratory (dental tech.: Roman Fr?czek)? The
internal surface of the onlay was adhesively prepared by sandblasting with 50 m aluminium oxide
(Fig 8 b), followed by silane and adhesive application.

Fig 8 b ?The internal surface of the composite onlay, sandblasted with 50 m aluminium oxide??
Tooth 17 was isolated with a rubber dam, and enamel and dentin were sandblasted with 50 m
aluminium oxide. Both enamel and dentin were etched (Fig 9), thoroughly rinsed with water spray,
and dried delicately (Fig 10), and adhesive (EnaBond) was applied meticulously (Fig 11).

Fig 9.?Enamel and dentin were etched with orthophosphoric acid...

Fig 10? ...then thoroughly rinsed with water spray, and dried delicately

Fig 11? ... and adhesive (EnaBond) was applied meticulously.?? Composite onlay was cemented with
light curing composite material (Enamel Plus, Micerium) heated to the temperature of 45-50 C
(EnaHeat, Micerium) (Fig 12).?

Fig 12 The indirect composite onlay was luted with light curing composite resin, heated to the

temperature of 45-50 C? ?All polymerized composite overhangs were removed with a scalpel, with
the rubber dam in place (Fig 13).

Fig 13
The clinical situation after polymerization of the luting composite resin and overhangs removal. ??
After rubber dam removal, the restoration was checked for any occlusal and functional adjustments
(Fig 14).?

Fig 14 ?The clinical outcome of the composite onlay after occlusal adjustments.? ?The patients followup appointment, one week later, did not reveal any pain and the pulp reaction was correct on the
vitality test (cold). Because, an increased occlusal activity was suspected as the main cause of the
tooth crack, the patient was scheduled for deprogrammation with a Kois Deprogrammer for four
weeks. Then the occlusal equilibration was obtained in order to remove all premature contacts. Finally
the patient received a Michigan maxillary occlusal splint according to Kois modifications for
continuous use while sleeping period.
The 12-month follow up can be seen on Fig 15.

Fig 15 ?The 12- month follow up of the cracked tooth 17, restored with indirect composite onlay.
1. Endo-Prosthodontics - The guidelines for the clinical practice - Zarow M, DArcangelo C, Felippe LA,
Paniz G, Paolone G; Quintessence Verlags -GmbH; Warsaw 2013
?2. http://aae.org/dentalpro/colleguenews.htm
?3. Willemsen W.L., van der Meer W.J. Repair and revision 4. Cracked tooth and crown fractures:
diagnostics and treatment. Ned Tijdschr Tandheelkd 2001;108(5):170172. ?
4. Roznowski M., Bremer M., Geursten W. Fracture resistance of human molars restored with various
filling materials. In: Moermann W.H. Proceedings of the international symposium on computer
restorations. 1991, Quintessence; Chicago:559566.
?5. Wassell R.W., Walls A.W., McCabe J.F. Direct composite inlays versus conventional composite
restorations: 5-year follow-up. J Dent 2000;28(6):375382.
?6. Krell K.V., Rivera E.M. A six year evaluation of cracked teeth diagnosed with reversible pulpitis:
treatment and prognosis. J Endod 2007;33(12):14051407. ?
7. Caplan D.J., Weintraub J.A. Factors related to loss of root canal filled teeth. ?J Public Health Dent
1997;57(1):3139.
?8. Z?arow M., Devoto W., Saracinelli M. Reconstruction of endodontically treated posterior teeth
with or without post? Guidelines for the dental practitioner. Eur J Esthet Dent 2009;4(4):312327.?

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