Bhañjanaka

The word Bhañjanaka is derived from the root Bhañj with the meaning of break down, tear down, shatter,
shiver or break to pieces, split. It also mean destroy by pulling down. Apte has given the meaning of
Bhañjanaka as – ‘ a particular disease of the mouth which consists the decay of the teeth attended with
contortion of the lips’ (Apte pg 399).

Sushruta Samhita has given three specific features in this disease-

1. Vakraṁ  Vaktraṁ Bhavēt – Distortion of the mouth or face.
2. Dantabhaṅgah – fracture of the teeth
3. Tīvraruk - acute pain
Astanga Hridaya has not considered this disease.
Dominance of dosa- kapha and vata dosa
Prognosis – Incurable disease असाध्योऽयं व्याधिः| (निबन्धसङ्ग्रह) 

All these features can be possible in fracture of the teeth or damage to trigeminal nerve.

Clinical features

वक्त्रं वक्रं  भवेद्यस्मिन् दन्तभङ्गश्च तीव्ररुक्  | 

कफवातकृ तो व्याधिः स भञ्जनकसञ्ज्ञितः ||सु. नि.  १६/३१|| 
वक्त्रं वक्रं  भवेद्यस्य दन्तभङ्गश्च जायते | 
कफवातकृ तो व्याधिः स भञ्जनकसञ्ज्ञितः || मा नि 56/२४|| 

Yasmin Vyādhiḥ Sa Bhañjanakasañjñitaḥ - That disease is called as Bhañjanaka in which

Vakraṁ  Vaktraṁ Bhavēt – mouth gets distorted,
Dantabhaṅgah – fracture of the teeth
Tīvraruk  ca- and also acute pain. Madhava Nidana has not accounted the pain.
Kaphavātakr̥tō – It is produced byKapha and Vāta
Vaidya Tatva Nirnaya Sagara has modified the vakra vaktra (deformity of the face) and specified that
there will be deformity only in the teeth – danta vakratva. It also substituted the word Prabhanjana for
Bhanjanaka.

Sushruta Samhita and Astanga Sangraha have discussed the management of fracture of the tooth
separately.

su chi 3/41-42

a s u 32/30

Updates on Cracked Tooth Syndrome

The most commonly affected teeth are- Mandibular second molars, mandibular first molars and maxillary
premolars.

The discomfort or pain in Cracked Tooth Syndrome (CTS) can mimic that arising from other pathologies,
such as sinusitis, temperomandibular joint disorders, headaches, ear pain, or atypical orofacial pain. But
early diagnosis is paramount as restorative intervention can limit propagation of the fracture, subsequent
microleakage, and involvement of the pulpal or periodontal tissues, or catastrophic failure of the cusp.

Dental History
Ask for the history of a course of extensive dental treatment involving repeated occlusal adjustments or
replacement of restorations, which fail to eliminate symptoms.

Besides pain on biting, the patient will also experience sensitivity to thermal changes, particularly cold.

Occasionally, there is sensitivity to sweets.

There can be instances when the patient may also remain asymptomatic for a long period.

Patients who have an existing cracked tooth are likely to have other cracked teeth.

Habits that might contribute to cracked teeth are clenching or grinding, chewing ice, pen, hard candy, or
other similar objects.

Clinical Examination
The presence of facets on the occlusal surfaces of teeth (identifies teeth involved in eccentric contact and
at risk from damaging lateral forces), the presence of localized periodontal defects (found where cracks
extend subgingivally), or the evocation of symptoms by sweet or thermal stimuli.

Many authors suggest removing existing restorations and stains once the tooth has been localized to
further aid in the visualization of the crack.

The use of rubber dam enhances the probability of visualizing these cracks by isolating the tooth,
highlighting the crack with a contrasting background, keeping the area free of saliva, and reducing
peripheral distractions.

Visual inspection of the tooth is useful, but cracks are not often visible without the aid of magnifying
loupes.

Scratch the surface of the tooth with the tip of a sharp explorer. The tip may catch in a crack.

Removal of existing restorations may reveal fracture lines.The decision to excavate should always be
made with the consent of the patient since it is not guaranteed that a fracture will be found underneath any
removed restoration.

Percussion Test-They are seldom tender to percussion (when percussed apically).

Periodontal probing - It helps to distinguish between a cracked tooth and a split tooth when the fracture
line extends below the gingiva, thereby causing a localized periodontal defect. For suspected cracks,
careful probing must be performed to disclose the presence of an isolated periodontal pocket. However,
isolated deep probing often indicates the presence of split tooth, which predicts a poor prognosis.

Dye Test -Gentian Violet or methylene blue stains can be used to highlight fracture lines. The
disadvantage of this technique is that it takes at least 2–5 days to be effective and may require placement
of a provisional restoration. Placing a provisional restoration undermines the structural integrity of the
tooth and further propagates the crack. An additional disadvantage is that a definitive esthetic restoration
cannot be obtained.
Transillumination - A crack that penetrates into the dentin of the tooth will cause a disruption in
the light transmission under these circumstances. There are two drawbacks to using transillumination
without magnification. First, transillumination dramatizes all cracks to the point that craze lines appear as
structural cracks. Second, subtle color changes are rendered invisible. Transillumination with a fiber-optic
light and use of magnification will aid in visualization of a crack.

Bite Tests- Bite tests can be performed using orange wood sticks, cotton wool rolls, rubber abrasive
wheels such as Berlew wheels, or the head of number 10 round bur in a handle of cellophane tape. The
patient is asked to bite on individual cusps separately. This helps to isolate the fractured cusp.

Vitality tests are usually positive. However, sometimes the affected teeth may display hypersensitivity to
cold stimuli due to the presence of pulpal inflammation, a feature that may help to confirm a diagnosis of
CTS.

Radiograph-Radiographs can aid in evaluating the pulpal and periodontal health of a tooth, but it is
rare to see a crack on a radiograph. The radiographs tend to be of limited use as fractures tend to
propagate in a mesiodistal direction, parallel to that of the plane of the film. However, they can be useful
in detecting more rarely occurring fractures which may run in a buccolingual direction and for excluding
other dental pathology.

Microscopic Detection-Use of the clinical microscope makes possible the treatment of

asymptomatic but structurally unsound posterior teeth.

Ultrasound - Ultrasound is also capable of imaging cracks in simulated tooth structure and could pose an
important diagnostic aid in the future. Where direct diagnostic methods prove unsuccessful, indirect
diagnostic methods like banding can be used to detect CTS. The use of copper rings, stainless steel
orthodontic bands, and acrylic provisional crowns may be placed on the tooth to prevent separation of the
crack during function. Upon review, following a period of 2–4 weeks after the application of immediate
splint, the absence of pain has been described to indicate not only a correct diagnosis but also successful
immobilization.

Another indirect diagnostic method is an unauthenticated technique which Banerji et al. mentioned in
their review on cracked teeth. They recommend placing composite resin over the tooth without etching
and bonding. The material is added and wrapped across the external line angles that act as a splint. The
patient when asked to bite finds a great reduction in discomfort as the material acts as a splint

Differentiating a Cracked Tooth from a Fractured Cusp or Split Tooth

If a crack can be detected, use wedging to test for movement of the segments to differentiate a cracked
tooth from a fractured cusp or split tooth. No movement with wedging forces implies a cracked tooth. A
fractured cusp may break off under slight pressure with no further mobility. A split tooth will show
mobility with wedging forces and the mobile segment extends well below the cemento-enamel junction.
Conditions that may be misdiagnosed as a cracked tooth involve the following: Acute periodontal disease,
reversible pulpitis, dentinal hypersensitivity, galvanic pain, postoperative sensitivity associated with
microleakage from recently placed composite resin restorations, fractured restorations, and areas of
hyperocclusion from dental restorations, pain from bruxism, orofacial pain, or atypical facial pain.