King’s Research Portal

DOI:
10.1038/sj.bdj.2017.398

Document Version
Peer reviewed version

Link to publication record in King's Research Portal

Citation for published version (APA):

Banerji, S., Mehta, S. B., & Millar, B. J. (2017). The management of cracked tooth syndrome in dental practice.
British Dental Journal, 222(9), 659-666. https://doi.org/10.1038/sj.bdj.2017.398

Citing this paper

Please note that where the full-text provided on King's Research Portal is the Author Accepted Manuscript or Post-Print version this may
differ from the final Published version. If citing, it is advised that you check and use the publisher's definitive version for pagination,
volume/issue, and date of publication details. And where the final published version is provided on the Research Portal, if citing you are
again advised to check the publisher's website for any subsequent corrections.
General rights
Copyright and moral rights for the publications made accessible in the Research Portal are retained by the authors and/or other copyright
owners and it is a condition of accessing publications that users recognize and abide by the legal requirements associated with these rights.

•Users may download and print one copy of any publication from the Research Portal for the purpose of private study or research.
•You may not further distribute the material or use it for any profit-making activity or commercial gain
•You may freely distribute the URL identifying the publication in the Research Portal
Take down policy
If you believe that this document breaches copyright please contact [email protected] providing details, and we will remove access to
the work immediately and investigate your claim.

Download date: 12. Nov. 2022

The management of Cracked Tooth Syndrome in
Dental Practice

Dr Subir Banerji 2 BDS MClinDent (Prosth) PhD MFGDP (UK)

Dr Shamir B. Mehta 1 BDS BSc MClinDent(Prosth) MFGDP (UK)

Prof Brian J Millar3 BDS FDSRCS PhD FHEA

1- Senior Clinical Teacher, Deputy Programme Director MSc Aesthetic Dentistry; 2- Programme Director MSc Aesthetic
Dentistry, Senior Clinical Teacher. 3- Professor, Consultant, Programme Director Fixed and Removable Prosthodontics

Corresponding Author

Dr Shamir B. Mehta

Address

Dept. of Conservative and MI Dentistry

Unit of Distance Learning,
Floor 18, Tower Wing, Guys Campus,
St Thomas’s Street,
London.
United Kingdom
SE1 9RT

Please email all correspondence to : [email protected]

1
Abstract
Cracked Tooth Syndrome is a commonly encountered condition in dental
practice, which frequently causes diagnostic and management challenges.
This paper provides an overview of the diagnosis of this condition, and goes
on to discuss current short and long-term management strategies applicable
to Dental Practitioners.

Clinical Relevance

This paper covers the diagnosis and management of this common condition.

Objectives

To inform clinicians of the current thinking, as well as to provide an overview

of the techniques commonly used in managing Cracked Tooth Syndrome.

Introduction

Cracks in teeth are exceedingly common. Some may be become problematic

and can lead to symptoms, cracked tooth syndrome and tooth loss.

A ‘crack’ may be defined as a ‘line on the surface of something along which it

has split without breaking apart’, whilst a ‘fracture’ may be considered to be
‘the cracking or breaking of a hard object or material’
(www.oxforddictionaries.com).1 Cracks on teeth may range from innocuous
craze lines limited to the enamel layer, to a split tooth or one that may display
the presence of a vertical root fracture. The term ‘incomplete fracture’, is used
to describe a fracture plane of unknown depth and direction passing through
tooth structure, that if not already involving, may progress to communicate
with the pulp or periodontal ligament’. 2 Where the fracture plane may
progress to the external surface of the tooth (either the clinical crown or root)
or to the pulp chamber (culminating in apical periodontitis), a diagnosis of a
complete fracture may apply. Complete and incomplete fractures may be
subdivided into those that take a vertical or oblique direction.3

Incomplete fractures of posterior teeth are commonly (but not always)

associated with the condition of cracked tooth syndrome, frequently
abbreviated to CTS. Patients presenting with CTS often complain of
symptoms of sharp pain on biting and thermal sensitivity, particularly during
the consumption of cold foods and beverages. 4 The intensity of the perceived
pain on biting is often proportional to the magnitude of the applied force. 5
Additional symptoms that are less frequently reported include, the perception
of pain on release particularly when fibrous foods are eaten (a phenomenon
termed ‘rebound pain’), pain elicited by the act of tooth clenching or grinding

2
or by sugary substrates and less commonly by heat stimuli respectively.
Sometimes, patients suffering from CTS are also able to accurately locate the
affected tooth. The precise cause of the symptoms associated with CTS is
unknown.6,7

The aim of this article is to provide an overview of the condition of CTS, as

well as to appraise traditional management strategies, including the
description of a recently described technique to assist with the diagnosis,
immediate management and subsequent treatment of CTS. It is however,
important to appreciate that as such no singular ’concrete’ method of
treatment can be advocated by the authors at this point in time for the
management of this problem. The latter is accountable for by a lack of depth
and detail in the available evidence, with much of the current data being
based on clinical audit(s) of a given approach, often where the sample sizes
have been relatively small or follow-up being of a relatively short duration.
There is also a need to take into account a variety of other factors, which may
be addressed when attempting to gain valid informed consent, taking into
additional account the skills and competence of an operator with a given
protocol. Clearly, there is a need for further research into the efficacy of
various techniques, ideally involving studies of the randomized controlled trial
variety or longer term prospective trials.,

The Epidemiology and Aetiology of CTS

Cracked Tooth Syndrome appears to typically affect adult patients that are
past their third decade, often affecting teeth that have previously received
restorative intervention, although not exclusively.8 Possible reasons include
older teeth having more restorations and may thus experience increased
lateral occlusal load due to the possible loss of anterior guidance over time.

Mandibular molar teeth seem to be most commonly involved, followed by

maxillary premolars, maxillary molars and mandibular premolars. In a recent
clinical audit, mandibular first molar teeth were most commonly affected by
CTS, possibly due to the wedging effect of the opposing prominent maxillary
mesio-palatal cusp onto the mandibular molar central fissure.9

The aetiology of CTS is multifactorial. Causative factors include, previous

restorative procedures, occlusal factors, developmental conditions/
anatomical considerations, trauma and miscellaneous factors (such an aging
dentition with a concomitant reduction in physiological elasticity or the
presence of lingual tongue studs).10

The Diagnosis of Cracked Tooth Syndrome (Figure 1)

The diagnosis of CTS is often based on the reporting of a history of cold

sensitivity and sharp pain on biting hard or fibrous food, with an alleviation of
symptoms on the release of pressure. However, the perceived symptoms may
display variation in accordance to depth and orientation of the crack.11 The

3
visual detection of a crack, often aided with the use of a sharp explorer probe
ideally with magnification, may help to confirm a suspected diagnosis;
however, not all cracks are symptomatic. The application of point load testing
devices to apply a force to a suspected fracture is risky, due to the possibility
of fracture of the tooth, restoration or the opposing tooth and therefore the
authors do not recommend their use.

Hypersensitivity to an applied cold stimulant (indicative of pulpal inflammation)

may also help to confirm a diagnosis of CTS. Affected teeth are however,
seldom tender to percussion, by virtue of the absence of a complete fracture
and the absence of irreversible pulpitis. The taking of radiographs to see a
coronal crack can be of a limited diagnostic benefit, as cracks may run parallel
to the plane of the film. The use of a light to trans illuminate a tooth can be
helpful. It has been suggested that yellow/orange lights may be of greater
value than blue light. However, blue lights are more readily available. Figure
1, includes a flow diagram, which may be used to assist with the diagnosis
and management of CTS.

Consensus opinion would suggest that the presence of a history of symptoms

as noted above, hypersensitivity to cold and a positive bite test are likely to
indicate the presence of an incomplete tooth fracture. However, in the opinion
of the authors it is common for a misdiagnosis to occur or indeed ambiguity to
exist over a precise diagnosis, which may prove frustrating to all concerned,
often necessitating specialist attention.12

The above is accounted for by there being several other conditions that may
yield similar symptoms to those of CTS, including some commonly
encountered conditions such as occlusal trauma, acute periodontal disease,
dentine hypersensitivity, galvanic pain, post-operative hypersensitivity,
fractured restorations, to less frequently diagnosed conditions such as
trigeminal neuralgia and atypical facial pain. 13 Establishment of an accurate
diagnosis may also be compounded by the lack of sensitivity offered by the
clinical tests described above and also by virtue of the presenting symptoms
often displaying diversity and inconsistency (which may also relate to the
exact depth and direction of the crack).9

The authors have recently described a useful clinically quick and easy way to
establish or confirm a diagnosis with the use of a “trial” localized supportive
composite splint.9 Here the suspected tooth exhibiting CTS symptoms of pain
upon release is isolated using cotton wool rolls. Resin composite is placed
onto the dried occlusal surface of the suspected tooth without any etching or
bond application to a thickness of 1.0 to 1.5mm and wrapped across the
external line angles of the tooth extending onto the (palatal/lingual and buccal)
axial walls by 2-3mm. No effort is made to contour the material. Once the
material has been cured, the un-bonded resin overlay has the potential to
serve as an occlusal splint. The patient is warned that the tooth will feel proud
and then asked to bring this tooth into contact with its antagonist and asked to
bite and slowly increase the pressure as a repeat of the initial “bite” test. The
absence of any pain upon release of the pressure may help to confirm a
suspect diagnosis of CTS. An example of a trial splint, is shown by Figure 3.

4
The Management of CTS

A number of differing protocols have been described in the contemporary

literature for the successful management of CTS.14 There is however, only
limited data available documenting the relative merits and drawbacks of each.
In the opinion of the authors, the selected protocol should offer an effective,
efficient, economic, predictable and biologically conservative means of
treating this condition.

Whilst some advocate the removal of the affected cusp, followed by

restoration of the residual defect or subtractive occlusal adjustments15, the
consensus approach for the management of incompletely fractured posterior
teeth would generally appear to involve the immobilization or splinting of the
affected tooth, so as to prevent the independent movement of the fractured
portions upon occlusal loading. Immobilization in this manner may also
prevent further progression of the fracture plane.16,17

Where removal of the fractured cusp is to be undertaken, it should be

performed with extreme caution, as there is a risk of attenuation of the
fracture plane. Subtractive occlusal adjustment is invasive and will not help to
avoid the continual flexure of the tooth upon loading when an occlusal load is
applied.8 Cusp reduction to overlay it with a protective restorative material
may be required: composite 2mm, gold and other alloys 1mm.

It is also important to check the anterior guidance when providing care. If

necessary thought may be given to the ‘building up’ of any worn anterior teeth
to increase the level of disclusion.

The Immediate Management of CTS

Traditionally, unless the affected cusp has been splintered off during the
removal of an existing restoration when undertaking exploratory procedures,
acute management has generally been provided using immediate extra-
coronal circumferential splints (such as copper rings,orthodontic bands or
provisional crowns) 18,19 or by the application of direct (intra-coronal or extra-
coronal splints) usually involving some form of tooth preparation, where some
levels of biological compromise is likely to be incurred. 20,21 Table 1 provides a
summary of the traditional protocols used for the immediate management of
CTS.

5
Table 1. A summary of some commonly used acute splints for the
management of CTS in General Dental Practice; 18,19,20,21

Method Advantages Disadvantages Other comments

1. Copper rings & - Can be effective -Not always at the - Must be well
stainless steel - Economical disposal of a GDP adapted
orthodontics bands - Minimally invasive - Skills & knowledge circumferentially
12,18 - Endodontic required to enable - Contoured
treatments may be correct placement. appropriately
performed whilst in - Placement may - Must not interfere
situ prove uncomfortable with the existing
- Can help to - Poor aesthetics occlusal scheme
establish a definitive - Food trapping with - Should remain in
diagnosis orthodontic bands situ for 2 to 4
weeks

2. Provisional - Can provide an - Time consuming to

crowns/overlays 19 effective means of prepare; undue
immobilization delays may result in
- Most General fracture progression
Dental Practitioners - Biologically
will be confident and invasive, with risks
competent with of pulp tissue
clinical techniques trauma 20,21

• Direct intra-coronal restorations

When using an intra-coronal restoration to treat an incompletely fractured

posterior tooth, the objective is to anchor the chosen dental material to the

6
cavity walls at either side of the fracture plane, which would help to not only
prevent the independent movement of the portions either side of the fracture
plane, but also aid in restoring the intrinsic fracture toughness of a tooth.

The use of adhesively retained silver amalgam restorations has been

described for the successful management of CTS. 22 However, the evidence
is very limited.

There is some evidence to support the short-term prescription of direct, resin

bonded posterior composite restorations to treat cases of CTS.23 Opdam et al
evaluated the efficacy of direct composite intracoronal resin restorations (to
treat painful, cracked posterior teeth where there were pre-existing silver
amalgam restorations). Cases were followed up for a period of seven years;
an annual failure rate of 6% was reported. This compared less favorably to
where a second sample had received directly bonded resin overlay
restorations. It was suggested that the inferior success of the intracoronal
approach might relate to the progressive breakdown of the adhesive interface
(between the tooth and restoration) with cyclical functional loading. The latter
would thereby hamper the longer-term ability of the restoration to effectively
splint the crack. This may be of particular concern amongst patients who may
display a tendency towards parafuntional tooth clenching and grinding habits.
Cuspal contraction that may also occur as a consequence of polymerization
shrinkage when placing composite resin restorations may have the unwanted
effect of causing further propagation of the fracture.

Two clinical studies have shown that the use of a flexible polymer resin such
as in SDR Bulk Fill (Dentsply)can reduce contraction stresses as well as
increase the risk of cusp fracture, which may prove to be of future merit.24,25

The longer term management of CTS

It has been suggested that the placement of a restoration that provides cuspal
coverage has the potential to restore the fracture toughness of a restored
tooth to that of an intact tooth.26 In the case of a posterior tooth with a crack
that has extended into dentine, it is reasonable to assume that the fracture
toughness of the affected tooth is likely to be undermined. For this reason, it
would seem prudent to restore such a tooth by the means of a restoration that
provides cuspal protection and limiting cuspal flexure. This may be achieved
by an onlay, overlay or crown restoration. Restorations that provide cuspal
coverage may be fabricated directly or indirectly.

• The use of direct onlay restorations to treat CTS

The use of direct materials to provide longer-term management of CTS has a

number of clear merits; Table 2 has summarized these.

Direct onlays used to treat incompletely fractured posterior teeth may be

formed using silver amalgam 27 or resin composite. 23 With the availability of

7
adhesively retained materials, direct silver amalgam overlays are rarely
provided in general dental practice.

Opdam et al, have reported very favorable longer-term success for the use of
direct resin onlays for the management of incomplete posterior tooth
fractures. The direct composite onlay restoration, therefore offers a lesser
invasive and aesthetic alternative to use of dental amalgam overlays for this
purpose.23 It is likely, that a reduction in the height of the affected cusp will
reduce the leverage placed on it when an occlusal load is applied, whilst the
its coverage with a plastic material will not only provide a form of ‘shock
absorption’ but also help to divert occlusal loads from the crack towards the
axial walls (to which the overlay will be anchored) and ultimately down the
long axis of the tooth (which may in turn also lessen the stresses applied to
the adhesive interface) and optimize restoration longevity.

Table 2. Merits of direct onlay restorations for the management of CTS.

- Restorations may be placed in a single visit; this may prove time

effective.
- Provisional restorations are avoided; provisional restorations are
not as well adapted as definitive restorations, which may facilitate
the continual ingress of noxious stimuli or microorganisms into the
crack. Provisional restorations will nether provide the same level of
cuspal support as a definitive restoration formed from a more robust
dental material.
- Costly laboratory fees are averted.
- Should endodontic therapy be subsequently required, pulp chamber
access through a direct restoration is less challenging than through
an indirect restoration; the resulting access cavity may be readily
repaired, without an absolute need to replace a costly indirect
restoration.

Indirect Restorations with cuspal coverage

Indirect techniques offer the use of dental materials which have the potential
to offer superior mechanical properties in the oral environment, and are
perhaps lesser demanding of operator skill versus the use and placement of
direct onlay restorations.14 When using occlusal coverage restorations, the
cusp angle should be reduced to reduce the risk of lateral loading.

Channa et al 28 have reported the successful application of resin bonded

alumina abraded Type III cast gold alloy onlays for the management of CTS
over a mean service period of 4.0 years. However, a relatively small sample
of cases was included. The latter restorations have the potential to offer
superior marginal adaptation and finish, favorable wear characteristics and a
high level of corrosion resistance.

8
The use of ceramic onlays to treat CTS should perhaps be undertaken with an
element of suspicion. Ceramics are relatively brittle materials, that display
limited ability of plastic deformation under load. The presence of a lower
elastic modulus in comparison to resin composite based materials culminates
in a superior ability (of the latter material) to absorb compressive loads by
57% versus that displayed by dental porcelains. 29 Thus, ceramics are less
likely (in theory) to offer desirable ‘shock absorbing’ properties, with the
possibility of an incomplete alleviation of symptoms as well as the risks of
continued fracture propagation. Furthermore, intra-oral adjustments with
dental ceramic materials may be challenging. There is however, very limited
data to support (or indeed contraindicate) the use of ceramic onlays to treat
CTS. 14 Given the current lack of any substantive evidence to contraindicate
the application of ceramic based materials for the management of CTS, it
would perhaps be appropriate to not completely discount their application for
the treatment of cracked teeth based simply on the findings of this laboratory
study alone as the evidence is not conclusive. Further evidence is clearly
required.

Indirect composite onlays may provide an aesthetic alternative to the use of

ceramic, with the merits of ease of adjustment, and repair (which may be
relevant if subsequent endodontic treatments are required). A retrospective
study by Signore et al has reported very promising results for the use of
bonded indirect resin onlays for the treatment of cracked, painful posterior
teeth. A survival rate of 93% over a period of six years amongst a sample of
43 teeth was determined.5

Indirect adhesive onlay techniques offer a more conservative alternative to full

coverage restorations. However, there still exists the need for subtractive
tooth preparations if restorations are to conform to the existing occlusal
scheme. The use of in-surgery CAD/CAM manufacturing techniques may
however offer some potential, by overcoming difficulties such as the
challenges associated with provisionalisation, which may increase the risks of
pulpal complications amongst incompletely fractured teeth.16

The prescription of full coverage crowns has been suggested to be the most
suitable form of treatment for the management of CTS.32 This is based on the
potential ability of the resistance form provided by such restorations to help
dissipate applied occlusal loads over the entire prepared tooth, as well as the
retention form (by frictional contact) to provide effectual immobilization.
Indeed, a bespoke preparation design has been advocated for cracked teeth
including; an additional level of reduction of the affected cusp.30

Full coverage crowns do not however offer a biologically conservative, time

efficient and cost effective approach to the management of CTS. Indeed,
endodontic complications have been documented as a significant concern
when adopting this protocol, with approximately one-fifth of a sample of 127
teeth affected by CTS requiring subsequent root canal treatment within the
first 6 months of placement.31 The risks of irreversible pulp trauma appear to
be exacerbated amongst teeth displaying an involvement of one of both of the

9
marginal ridges; furthermore, the prognosis of cracked, root filled teeth has
been reported to be poor, Tan et al.32

Teeth with symptomatic, incomplete fractures are likely to display a form of

reversible pulpitis. It is likely that the further trauma of subtractive preparations
(to receive overlay restorations) coupled with the use of provisional
restorations, pulp tissue trauma sustained during restoration try-in (which may
also involved further tooth desiccation) and cementation will further increase
the ‘stresses’ placed on the already inflamed and irritated tissues. This in turn,
will further curtail the efficacy and predictability of indirect restorations to treat
teeth affected by CTS (especially where more invasive preparation designs
are applied).

• A novel ultra-conservative approach to the management of CTS.

(Figure 2)

As an extension to the placement of a supra-coronal trial, directly non-bonded

direct resin overlay (applied without any tooth preparation) to further help
establish a diagnosis for CTS as described above, Banerji, Mehta, Millar et al
have reported the successful placement of bonded, direct supra-coronal resin
onlay restorations (DCS) for the treatment of incompletely fractured teeth by
the means of a multi-centered retrospective audit, with an overall 86.7%
success rate within 3 months of placement.9

The principles of this approach are based on those of well documented

concepts of ‘relative axial movement’, which is commonly utilized to treat
patients with pathological tooth, wear by minimal intervention.33-36

Supraocclusal restorations should be contoured to be flat so as to limit lateral

loading. Given that definitive restorations have occlusal contour then the
definitive restoration is not ideal for this use although they have been shown
to be effective, Gerasimidou et al.37 In each case, a careful assessment of
placing a restoration in supra-occlusion was carried out, noting the eruptive
potential of the patient, the risks of placing a supra-coronal restoration of the
patient’s oral health and informed consent was gained. Factors which may
suggest the presence of a reduced eruptive potential include; the presence of
an open bite, dental implants, fixed bridgework (with an abutment either side
of the space), bony ankyloses, severe Class III malocclusions and the
presence of prominent bony exostoses. Conditions which may also preclude
the prescription of a supra-coronal restorations include; active periodontal
disease, TMJPDS, prior orthodontic treatment, a heavily restored tooth (for
instance a root filled tooth) or where the antagonistic tooth may be vulnerable
to fracture.

However, intracoronal restorations should never be placed in supraocclusion,

as they increase pulpal pain and may cause cusp fracture. Intentionally high
restorations must have full occlusal coverage, free of endodontic pathology
(including root canal fillings), no pathology present, with patient understanding
and consent.

10
The clinical steps involved for this technique include (Figures 3 to 13) and a
flow diagram is also provided (Figure 2):

• Confirming the complete elimination of the symptoms of rebound pain

from the diagnosed tooth with a non-bonded composite splint as
described above.

• An evaluation of the periapical status and bone support with an

accurate long cone periapical radiograph.

• An explanation of the technique should be provided to the patient,

outlining the nature of the treatment along with instructions for
anticipating the change in their occlusal scheme.

• The application of a slurry of pumice the occlusal and axial walls of the
diagnosed tooth, or the alternative use of air-abrasion techniques.

• Conditioning for adhesive bonding using a total etch technique,

involving the use of 37% phosphoric applied over the occlusal and the
axial walls for 20secs, followed by thoroughly washing the surfaces and
the subsequent drying of the etched surfaces.

• Placement and curing of the chosen bonding resin as per the

manufacturers instructions.

• Placement of a composite resin on the occlusal surface and 2-3mm

down the axial walls (buccal, palatal/lingual). The depth of composite
resin placed on the occlusal surface should be to 1.0-1.5mm in
thickness, along the axial walls composite to finish in an infinity bevel
and supragingivally. Light cure to manufacturers instructions.

• The occlusal surface should to remain ‘flat’ with the absence of any
contact during any excursive mandibular movements. In certain
instances a canine rise may be added in composite to achieve this.

• Composite to be polished.

• The patient should be reviewed within in 1 week to confirm alleviation

of symptoms, followed by a periodic review every 2 weeks until all
other tooth contacts are re-established.

• Substitution the composite splint with a definitive adhesive restoration

once other tooth contacts reestablished. Remove canine rise
restoration if required.

11
Whilst further work is needed to fully support this approach, the use of a DCS
restoration has the potential (where careful case selection is applied) to
provide a conservative, effective, predictable, efficient and economical
approach to the short to medium term management of CTS. It may be
particularly appropriate where there may exist a doubt over the exact
diagnosis. An extrapolation of this approach, may involve the placement of
indirect adhesive onlays in supra-occlusion as a means for the long-term
management of incompletely fractured teeth in an ultra-conservative manner,
where there is little doubt over the diagnosis.

With the advancement of CAD-CAM technology the fabrication of the

proposed onlay can now be produced at the chair side once the diagnosis has
been established.

Conclusion

The diagnosis and management of CTS in dental practice can sometimes

prove to be highly taxing on the operator. There is a need for an effective
technique to provide immobilization. The DCS restoration may have
considerable merits for the diagnosis and management of CTS in a
predictable and minimally invasive manner. However, there is a need for
further research into this technique, as well as into alternative forms of
management as discussed above, in order to support (or indeed
contraindicate) the notion of any one approach (inclusive of a given dental
material and or restoration form) being superior to another.

12
References

1. Crack – definition of crack in English form the Oxford dictionary

www.oxforddictionaries.com > dictionary.
2. Ellis SG. Incomplete tooth fracture-proposal for a new definition. Br
Dent J 2001; 190: 424-428.
3. Silvestri A, Singh I. Treatment rationale of fractured posterior teeth. J
Am Dent Assoc 1978; 97 : 806-810.
4. Cameron CE. The cracked tooth syndrome: additional findings. Jour Am
Dent Assoc 1976; 93: 971-975.
5. Signore A, Benedicenti S, Covani U. Ravera G. A 4 to 6 year
retrospective clinical study of cracked teeth restored with bonded
indirect resin composite onlays. Int Jour Prosthodont 2007; 20: 609-616.
6. Davis R, Overton J. Efficacy of bonded and non-bonded amalgams in
the treatment of teeth with incomplete fractures. Jour Am Dent Assoc
2000; 131: 496-478.
7. Dewberry JA. Vertical fractures of posterior teeth, Lieve FS(ed)
Endodontic Therapy, 5th edition. St Louis: Mosby, 1996: 71-81.
8. Hiatt WH. Incomplete crown-root fractures in pulpal periodontal disease.
J Periodontol 1973; 44: 369-379.
9. Banerji S, Mehta SB, Kamran T, Kalakonda M, Millar BJ. A multi-
centered clinical audit to describe the efficacy of direct supra-coronal
splinting – A minimally invasive approach to the management of
cracked tooth syndrome. Journal of Dentistry 2014;42:862-871.
10. Lynch C, McConnel R. The cracked tooth syndrome. Jour Can Dent
Assoc 2002; 68: 470-475.
11. Geurtsen W, Schwarze T, Gunay H. Diagnosis, therapy and prevention
of the cracked tooth syndrome. Quintessence Int 2003; 34: 409-417.
12. Banerji S, Mehta SB, Millar BJ. Cracked tooth syndrome. Part 1 :
aetiology and diagnosis. Br Dent J 2010; 208 : 459-463.
13. Turp C, Gobetti J. The cracked tooth syndrome: an elusive diagnosis.
Jour Am Dent Assoc 1996; 127: 1502-1507.
14. Banerji S, Mehta SB, Millar BJ. Cracked tooth syndrome. Part 2 :
restorative options for the management of cracked tooth syndrome. Br
Dent J 2010; 208 : 503-514.
15. Agar JR, Weller RN. Occlusal adjustments for initial treatment and
prevention of cracked tooth syndrome. Jour Prosthet Dent 1988; 60:
145-147.
16. Griffin J. Efficient, conservative treatment of symptomatic cracked teeth.
Compendium 2006; 27: 93-102.
17. Liebenberg WH. Partial coverage indirect tooth coloured restorations;
steps to clinical success. Am Jour Dent 1999; 12: 201-209.

13
18. Ehrmann EH, Tyas MJ. Cracked tooth syndrome: diagnosis, treatment
and correlation between symptoms and post-extraction findings.
Australian Dent Jour 1990; 35: 105-112.
19. Gutherie GC, Difiore PM. Treating the cracked tooth with a full crown.
Jour Am Dent Assoc 1991; 122: 71-73.
20. Saunders WP, Saunders EM. Prevalence of periradicular periodontitis
associated with crowned teeth in an adult Scottish subpopulation. Br
Dent J 1988; 185: 137-140.
21. Cheung GS, Lia SC, Ng RP. Fate of vital pulps beneath a metal ceramic
crown or a bridge retainer. Int Endod Jour 2005; 38: 521-530.
22. Bearn D, Saunders E, Saunders W. The bonded amalgam restoration –
a review of the literature and report of its use in the treatment of four
cases of cracked tooth syndrome. Quintessence Int 1994; 25: 321-326.
23. Opdam NJ, Roeters JJ, Loomans RA, Bronkhorst E. Seven year clinical
evaluation of painful, cracked teeth restored with a direct composite
restoration. J.Endod 2008; 34: 808-811.
24. Van Dijken JW. Randomised 2-year follow-up of posterior bulk-filled
resin composite restorations. Presented at the 46th Meeting of the
Continental European Division of the International Association for
Dental Research with the Scandinavian Division (NOF). Florence. 2013.
Available from:
http//www.dentsply.co.uk/products/restorative/composites/SDR
(accessed September 2014).
25. McGuirk C, Hussain F, Millar BJ (2016). Survival of direct posterior
composites with and without a bulk fill base, Int Dent J in press
26. Hodd JAA. Biomechanics of the intact, prepared and restored tooth;
some clinical implications. Int Dent Jour 1991; 41: 25-32.
27. Davis R, Overton J. Efficacy of bonded and non-bonded amalgams in
the treatment of teeth with incomplete fractures. Jour Am Dent Assoc
2000; 131: 496-478.
28. Chana H, Kelleher M, Briggs P, Hopper R. Clinical evaluation of resin
bonded gold alloys. Jour Prosthet Dent 2000; 83: 294-300.
29. Brunton PA, Cattell P, Burke FJT, Wilson NHF. Fracture resistance of
teeth restored with onlays of three contemporary tooth-coloured resin-
bonded restorative materials. Jour Prosthet Dent 1999; 82: 167-171.
30. Casciari BJ. Altered preparation design for cracked teeth. Jour Am Dent
Assoc 1991; 130: 571-572.
31. Krell K, Rivera E. A six year evaluation of cracked teeth diagnosed with
reversible pulptitis ; treatment and prognosis. J Endod 2007; 33: 1405-
1407.
32. Tan I, Chen NN, Poon CY, Wong HB. Survival of root filled cracked
teeth in a tertiary institution. Int Endod Jour 2006; 39: 886-889.
33. Dahl B, Krungstad O, Karlsen K, An alternative treatment of cases with
advanced localised attrition. J Oral Rehab. 1975;2: 209-214.

14
34. Dahl B, Krungstad O. Long term observations of an increased occlusal
face height obtained by a combined orthodontic/ prosthetic approach. J
Oral Rehab. 1985; 12: 173-170.
35. Poyser N, Porter R, Briggs P, Chana H, Kelleher M. The Dahl concept:
past, present and future. Br Dent J; 2005; 198: 669-676.
36. Hemmings K, Darbar U, Vaughn S. Tooth wear treated with direct
composite at an increased vertical dimension: results at 30 months. J
Prosth Dent. 2000; 83:287-293.
37. Gerasimidou O, Watson T, Millar BJ (2016). Effect of placing
intentionally high restorations: randomized clinical trial. Journal of
Dentistry 2016 in press.

15
Figures

Figure 3. An example of a trial localised supportive composite splint

Figure 4. The lower right second molar has been diagnosed with CTS
symptoms with ‘rebound pain upon biting on a cotton wool roll.

Figure 5. Following confirmation of the alleviation of symptoms with a “trial”

splint (as shown in Figure 1) a bonded Direct Composite Splint (DCS) is
placed on the lower right second molar tooth.

16
Figure 6. The separation of the teeth is shown here following placement of the
DCS.

Figure 7. Shows upon right lateral excursion the posterior teeth along with the
tooth with the DCS is out of contact with lower right canine guidance.

Figure 8. The teeth have now re-established contact in the intercuspal

position and the symptoms are resolved from the lower right second molar
tooth.

17
Figure 9. The DCS has been replaced with a Direct composite onlay following
resolution of symptoms and reestablishment of the occlusion.

Figures 10 Shows another case where the diagnosed lower left second tooth
has had placement of the DCS.

Figure 11. Shows teeth are held separated by the DCS for the case shown in
figure 10, however there is no posterior teeth contacting on any excursive
movements of the mandible.

18
Figure 12. The occlusion has been re-established after a period of 3 months
following DCS placement for case shown in figure 10.

Figure 13. The DCS has been replaced with a Type III cast adhesive gold
onlay for the case shown in figure 10.

19
Figure 2: A novel ultra-conservative approach to the management of
CTS.

20
 Figure 1 CTS flow chart – A guide to diagnosis and management

Symptoms
Listen to the patient Signs
Pain – sharp and localised Look with illumination and
Pain on biting/release magnification
Thermal sensitivity, especially to Fracture line(s) – inspection with probe,
cold transillumination, location Tests
? Tooth wear – check occlusal contacts Cold
and disclusion test
Restorations – weaken teeth, hide Bite test
fractures DCS
Diagnosis of CTS
Exclude: periodontal/periapical
causes, galvanic action, facial
pain, exposed dentine, post-op
Immediate protection
pain
DCS excludes apical pathology Splinting – DCS, bands
Assess pulp status - ?RCT
needed
Canine riser or splint needed? ? Intrude
Hopeless prognosis RCT
Deep subgingival If apical
fracture symptoms
Unrestorable If restorable Long term management
Protect with occlusal
coverage
RCT unsuccessful Monitor pulp status
Extract
If canal system reinfects Monitor tooth wear
(fracture unrestorable)

21