America's Dental Bookstore

(for instructions on using this site, see our home page)

America's Dental Bookstore

Dental Books
Anatomy Books Anesthesia & Sedation BooksBehavior of Patients
Clinical Dentistry & Treatment PlanningCosmetic Dentistry BooksDental Assisting Books
Dental EmergenciesDental Hygiene BooksDental MaterialsEndodontics
Fixed ProsthodonticsHistory of DentistryHumor ImplantologyLaboratory Technology
MicrobiologyOcclusion & TMJ BooksOral BiologyOral Pathology & Oral Medicine
Oral PhysiologyOral SurgeryOrthodonticsPediatric DentistryPeriodontics & Prevention
PharmacologyPractice ManagementPractice Mgmt. Finance & Regulations
Practice Mgmt. MarketingPractice Mgmt. TheoryPsychology & Patient AnxietyRadiology
Removable ProsthodonticsRestorative DentistryTest Preparation Books

Consumer Information Books
Amalgam & MercuryBraces Children's BooksGeneral Care & Misc. Books
Consumer Information About Cosmetic DentistryDental Articles

Anesthesia & Sedation ArticlesClinical Dentistry ArticlesCosmetic Dentistry ArticlesDental Assisting ArticlesDental Hygiene ArticlesDental Humor ArticlesDental Materials ArticlesEndodontics ArticlesFixed Prosthodontics ArticlesImplant ArticlesLaboratory Technology ArticlesOral Surgery ArticlesOrthodontics ArticlesPedodontics ArticlesPeriodontics and Prevention ArticlesPractice Finance & Regulations ArticlesPractice ManagementPractice Management - MarketingRadiologyTest PreparationTMJ and Occlusion Articles

Do Endo With Crown Prep • Saving Fractured Teeth • Enhanced Irrigation Solutions

To browse America's Dental Bookstore huge selection of dental books, click here.
Click here to find books about endodontics.

This article was published in Portuguese in the Revista Paulista de Odontologia,
Sao Paulo, Brazil, Jan-Feb 2004 issue, pp. 10-15.
An English version of this article was published in the
Journal of the Colorado Dental Association, Fall 2004 issue.

"Because people are living longer and dentists are helping keep teeth longer, teeth are being exposed to years of crack inducing habits.  Particularly, clenching, grinding, and chewing hard things such as ice can result in cracks and fractures in teeth.  Typically cracks and fractures do not show on x-rays.  Hence, cracked and fractured teeth can especially be difficult to locate."                   source:


Symptoms of a cracked or fractured tooth

A fractured or cracked tooth will sometimes have a sharp pain when you bite on it, but not always. Sometimes the pain will come as you release pressure on the tooth. The symptoms can also be a sensitivity to cold or to hot. And, you may have symptoms of a cracked or fractured tooth and then ask your dentist to tell you what is wrong, but he or she may be unable to tell. It is extremely rare for a crack or a fracture to show up on an x-ray, because it will only appear if the x-ray happens to be at the exact same angle as the crack. Therefore, cracks and fractures are often diagnosed from the associated signs, such as infection, that follow a long-standing crack or fracture.



The treatment of a split or fractured tooth has historically been extraction. Below is a synopsis of Dr. David Hall's landmark study, demonstrating that these teeth, if the split or fracture is caught early, can be restored and they can heal.



When a vertical tooth fracture extends subgingivally to below the gingival attachment, the literature practically universally recommends extraction.[1][2][3][4][5][6] Walton phrases this recommended treatment thus:  Once the clinician confirms the diagnosis of a fractured tooth, “Maintaining an intact tooth is impossible.” He continues: “If the fracture is severe (that is, deep apically), the tooth must be extracted. If the fracture shears to a root surface that is not too far apical, the smaller segment will be very mobile. Then there is a good possibility that the small segment can be removed and the remainder of the tooth salvaged.”[1]

The rationale can be expressed as the following: When a fracture traverses the area from the supragingival area to below the attachment, the fracture line becomes a focal point for inflammation. Simon, Glick and Frank, in their article in Oral Surgery put it this way: “Once this attachment is breached and the groove becomes involved, a self-sustaining infrabony pocket can be formed along its length. This condition is nonresponsive to periodontal treatment.”[7]

In the paper referenced below, Hall, Ourique, and Itikawa offer literature references to provide a rationale for believing that these teeth can be saved, as well as case studies of from ten to twenty-one years duration that show examples of fractured teeth that have been successfully treated. These teeth have remained intact and fully healthy for as long as they have been observed.

We will present here a paraphrasing of their original article, and will reference the complete source at the bottom of the page.

Background (literature references):

We all know that roots are covered with cementum. The cells that create cementum are in the periodontal ligament. Furthermore, it is common knowledge that cementum deposition occurs throughout life.[8] It doesn't take much of a leap to presume that, if there were to be an injury to a root such as a crack, and if the proper conditions were to exist, that there could be a potential for that crack to be able to heal over with new cementum.

Searching the literature, we were able to find a few reports of such healing actually occurring. Hammer[9] studied tooth fractures in dogs and noted, after two weeks, dentin repair beginning on the pulpal side of the fracture, and cementum repair on the periodontal ligament side of the fracture line after three weeks.

Andreasen and Hjørting-Hansen did their study of cementum healing by observing human teeth.[10] Their study included 50 horizontal root fractures. By radiographic examination, they showed the apparent formation of new cementum when the fractured segments were in close apposition. Furthermore, one of these teeth was extracted and it showed, clinically, the formation of cementum and cementoid. As a result of their study, they concluded that the two most important features in the successful treatment of root fractures are immediate reposition and fixation.

Both of these studies involved horizontal root fractures that were entirely below the gingival attachment. The question remains as to whether the same processes can work to heal vertical fractures that traverse the attachment.

In a case report by Hall in the Journal of the American Dental Association, a traumatic injury to an 11-year-old made resulted in a central incisor being shattered into four pieces, and being subsequently restored.[11] The trauma had caused several vertical fractures which traversed the gingival attachment. Eighteen months postoperatively, in spite of pulpal involvement in the fractures, the tooth was still vital and apparently completely healthy. However, in spite of the initial success of the treatment and after the publishing of the case report, the tooth was re-fractured in a second traumatic incident. Upon examining the second injury, Hall was able to separate the coronal portions of the injury only very slightly. The complete resistance to separation of the radicular portions was consistent with cementum healing having occurred over the first injury. Repair was attempted after the second injury, but without long-term success. Five years later, the tooth was extracted. However, the incident suggested a possibility of true cementum healing of a vertical root fracture.

In the 1980’s, Japanese researcher Masaka[12] developed a technique for preserving teeth that had suffered vertical root fractures by using a 4-META adhesive. What he did was to extract fractured teeth, repair them extraorally, and then replant them in the patient. While his success validates the concept of root fracture repair, it doesn’t address the issue of potential biological cementum repair. French researcher Aouate[13] has also performed similar work in vertical root fracture repair using 4-META.

To read the report of cases in the work primarily done by Hall, click here.


[1] Walton, R.E. Principles of endodontics, ed. 2. Philadelphia, W.B.Saunders Co., p 485. 1996.

 [2] Stanley, J.R. The cracked tooth syndrome. J Am Acad Gold Foil Operators 11:36-47, 1968.

 [3] Snyder, D.E. The cracked-tooth syndrome and fractured posterior cusp. Oral Surg 41:698-704, 1976.

 [4] Ritchie, B..; Mendenhall, R.; and Orban, B. Pulpitis resulting from incomplete tooth fracture. Oral Surg, Oral Med, Oral Pathol 10:665-671, 1957.

 [5] Linaburg, R.G. and Marshall, F.J. The diagnosis and treatment of vertical root fractures: report of case. JADA 86:679-683, 1973.

 [6] Plant, J.J., and Uchin, R.A., Endodontic failures due to vertical root fractures: two case reports. J Endodont 2:53-55, Feb. 1976.

 [7] Simon, J.H.S.; Glick, D.H.; and Frank, A.L. Predictable endodontic and periodontic failures as a result of radicular anomalies. Oral Surg 31:823-826. June 1971.

 [8] Lefkowitz, W. The formation of cementum. Am J Ortho 30:224-240. May 1944.

 [9] Hammer, H. Die Heilungsvorgänge bie Wurzelbrüchen. Deutsch Zahn Mund Kieferheilk 6:297, 1939.

 [10] Andreasen, J.O., and Hjørting-Hansen, E. Intraalveolar root fractures: radiographic and histologic study of 50 cases. J Oral Surg 25:414-426. Sept. 1967.

 [11] Hall, D.A. Restoration of a shattered tooth – report of a case. JADA 129:105, Jan. 1998.

 [12] Masaka N. Long-term observation of fractured tooth roots preserved by adhesion. Adhesive Dentistry. Japanese 13:156-170, 1995.

 [13] Aouate, G. Treatment of an intra-alveolar root fracture by extra-oral bonding with adhesive resin. Information Dentaire. French 26:2001-2008, 2001.

More articles
America's Dental Bookstore maintains this collection of articles on dentistry submitted by visitors to our site. These could be clinical tips, research articles, opinion articles, dental jokes, or whatever. Do you have something you'd like to submit? If so, click here to submit an article.