JJOD-2252; No.

of Pages 10

journal of dentistry xxx (2014) xxx–xxx

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/jden

A multi-centred clinical audit to describe the

efficacy of direct supra-coronal splinting – A
minimally invasive approach to the management
of cracked tooth syndrome

S. Banerji a, S.B. Mehta a, T. Kamran b, M. Kalakonda c, B.J. Millar d,*

a
King’s College London, London, United Kingdom
b
Department of Primary Dental Care, King’s College London, London, United Kingdom
c
General Dental Practitioner, United Kingdom
d
Primary Care Dentistry, King’s College London, Dental Institute at Guy’s, King’s College & St. Thomas’ Hospitals,
London, United Kingdom

article info abstract

Article history: Objectives: This audit looked at the use of direct composite splinting to manage cracked
Received 11 December 2013 tooth syndrome (CTS).
Received in revised form Methods: Patients who had been assessed as having CTS were offered the treatment of a
2 February 2014 directly bonded, composite overlay restoration placed in supra-occlusion. Cases were
Accepted 20 February 2014 reviewed up to 3 months later.
Available online xxx Results: In all, 151 restorations were followed up in the audit of which 131 were successful at
3 months. The remaining 20 restorations failed due to pulp complications (11), failure of the
Keywords: composite (5) or intolerance to the high restoration (4). Of the 131, patients described
Cracked teeth transient problems with chewing (94), composite breakage (13), TMD (1), phonetics (1),
Composite splint increased mobility (1) and tender to chewing (1).
Supra-occlusion Conclusions: This is a successful non-invasive method of managing CTS in the short term for
patients willing to accept transient effects.
# 2014 Elsevier Ltd. All rights reserved.

Clinical significance 1. Introduction

The use of a minimally invasive directly bonded composite flat
occlusal splint for the symptomatic management and con-
comitant protection of teeth diagnosed with cracked tooth
syndrome was described previously. This audit assesses its
efficacy amongst 151 cases. In all, 131 were successful and
reported a reduction in symptoms before proceeding to
further treatment.
Incomplete fractures of posterior teeth are typically associated
with the symptoms of sharp pain during biting and thermal
hypersensitivity, usually to cold stimuli. The condition is
usually referred to as ‘cracked tooth syndrome’ (CTS).1 The
aetiology of CTS is often multi-factorial.2
The presenting symptoms of this condition can however
display considerable variance, thereby sometimes leading to

* Corresponding author at: Primary Care Dentistry, King’s College London, Dental Institute at Guy’s, King’s College & St. Thomas’ Hospitals,
Bessemer Road, London SE5 9RW, United Kingdom. Tel.: +44 020 7848 1235; fax: +44 020 7848 1366.
E-mail address: brian.millar@kcl.ac.uk (B.J. Millar).
http://dx.doi.org/10.1016/j.jdent.2014.02.017
0300-5712/# 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
JJOD-2252; No. of Pages 10
2 journal of dentistry xxx (2014) xxx–xxx
confusion and misdiagnosis. A range of dento-facial disorders
have been frequently incorrectly diagnosed as CTS3 and are
listed in Table 1.
It is generally accepted that a history of pain on biting (or
particularly on release), coupled with thermal hypersensitivity
to cold and hyper-sensitivity to an applied cold stimulus,
together with a positive response to a ‘bite test’ is sufficient to
arrive at a diagnosis of CTS.2 However, in the opinion of the
authors, there is a lack of sensitivity with this approach.
The active restorative management of CTS is not simple;
however there is consensus for the need of immobilisation. A
splint should aim to prevent the independent movement of
the fractured portions upon the application of a bolus to the
affected tooth and prevent further progression of the fracture
plane.4
In the acute scenario, symptomatic management has been
achieved by the placement of copper rings, stainless steel
orthodontic bands or provisional crowns to the affected
tooth.5,6 Copper rings and orthodontic bands are however
seldom at the ready disposal of most General Dental
Practitioners, are not well accepted by the periodontal tissues
and furthermore may be associated with aesthetic concerns.
The application of provisional, full coverage crowns is
biologically invasive,7,8 costly, irreversible and time consum-
ing. Furthermore, there is a risk of overtreatment if the
diagnosis is incorrect which a direct coronal onlay splint (DCS)
avoids.
A variety of protocols have been described in the
contemporary literature for the definitive management of
incomplete posterior tooth fractures, ranging from the
application of directly bonded intra-coronal restorations,9–11
directly bonded extra-coronal restorations10–12 and indirect
extra-coronal restorations with varying amounts of tooth
coverage.13–15 The use of CAD-CAM-fabricated restorations
has also been suggested.16
Evidence exists for the successful, medium-term use of
directly bonded resin restorations10,11 and indirect resin
composite onlays13 to treat cases of CTS. Opdam et al.,10,11
have described a relatively good short term outlook for teeth
affected by CTS to be managed by the placement of direct
intra-coronal resin bonded composite restorations, offering a
protocol with minimal subtraction (particularly in the pres-
ence of a pre-existing restoration). However the medium to
longer term efficacy of this form of restoration appears less
predictable over one which offers cuspal coverage, perhaps
accounted for by an eventual breakdown of the adhesive
interface between the restoration and affected tooth from the
effects of cyclical loading.11 In order to provide cuspal
coverage without prescribing a change in the intercuspal
position, a more invasive protocol is usually necessitated.
In 2010, Banerji et al. proposed the DCS based on the well-
established concept of the ‘Dahl’ phenomenon17,18 (perhaps
Table 1 – A list of conditions/signs frequently misdiagnosed for CTS.
Acute periodontal disease
Galvanic pain
Hyper-occlusion
Atypical facial pain
Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
more accurately described as relative axial tooth movement,
intrusion and extrusion, or occlusal adaption) as a possible
means of effectively, efficiently and economically treating CTS
in a minimally invasive manner.19 The DCS restoration
comprises a direct, ‘flat’ composite resin onlay applied
without any tooth preparation across the entire occlusal
surface, carried over across the external line angles to extend
at least one-third of the way down the axial (buccal, lingual or
palatal) walls, respectively. Consequently, it is placed in a
supra-occlusal position. The use of supra-coronal adhesive
onlay restorations to treat cases of CTS in a minimally invasive
manner is not a novel concept.15 There are, of course, certain
limitations and indeed contra-indications to this approach.
The Dahl concept has been historically, successfully
applied for the management of localised anterior tooth wear,
as a means of creating intra-occlusal clearance without the
need for further tooth reduction.20–25 The phenomenon refers
to the tooth movements that take place when a localised
appliance is placed in the supra-occlusal position, followed by
the concomitant re-establishment of full-arch contacts over a
period of time.26
A DCS can have several applications. In the first instance, it
may serve as a diagnostic aid. Indeed, the authors initially
advocated the placement of the DCS onlay restoration as a
‘trial approach’ (without the use of an adhesive), so as to not
only ascertain initial tolerance by the patient but to also help
confirm that the symptoms are from a specific tooth, that the
source of pain is pulpal and not periapical in origin. When
directly bonded it may also provide relief from the symptoms
of CTS by providing extra-coronal fixation and reduce fracture
risk. Finally, a DCS restoration also has the potential to provide
the necessary intra-occlusal clearance required to accommo-
date a more suitable definitive restoration without the further
need of hard tissue removal.19
This technique has been in use for some time since initial
publication, and therefore, the authors considered an audit
was due. The aim of this paper is to describe the outcome for
the use of DCS restorations to treat cases of CTS by the means
of a multi-centred retrospective audit where a universal
protocol had been applied.19
2. Materials and methods
A total of 151 patients diagnosed with CTS were included in
this multi-centred retrospective audit. Patients had been
treated at one of four separate General Dental Practices based
in South-East England or at the King’s College London Dental
Institute, London (KCLDI). Overall, five trained operator/
assessors were involved each known to the other either in
the capacity of colleague, Senior Clinical Teachers or post-
graduate Masters level students at the KCLDI. DCS restorations
Reversible pulpitis Dentinal hypersensitivity
Post-operative sensitivity Fractured restorations
Occlusal trauma Trigeminal neuralgia
JJOD-2252; No. of Pages 10

journal of dentistry xxx (2014) xxx–xxx 3

were being offered by each of the assessors as a form of routine
therapy for the management of patients presenting with
symptoms of cracked tooth syndrome by minimal interven-
tion.
A diagnosis of CTS had been derived where patients had
initially reported a history of pain on chewing (or release) and
thermal hypersensitivity to cold stimuli, a positive response to
a ‘bite test’ and an exaggerated response to a cold stimulant
when applied to the affected tooth. Bite tests were performed
using a Tooth Slooth crack detector (Professional Results,
USA).2 Sensitivity testing was carried out using a cotton wool
pellet soaked with ethyl chloride (Endo-Cold Spray, Henry
Schein). Each patient also provided a negative response or the
complete alleviation of the symptom of pain on biting or
release following the application of a ‘trial’ (non-bonded)
extra-coronal splint to the suspected tooth.
For the provision of a non-bonded DCS suspected teeth
were dried with air and composite resin (Gradia Direct, GC
Corporation, Tokyo, Japan) was applied to the occlusal aspects
of the teeth. Resin composite placement was carried along
over the external line angles of the affected tooth, down onto
the axial walls to approximately 3 mm short of the gingival
margin. No local anaesthesia or alteration of the retentive (and
adhesive) capacity of the affected tooth respectively was
required in any case. Resin composite was applied to attain an
ultimate thickness of approximately 1.5 mm over the occlusal
surface and 1.5–1.0 mm along the axial walls and cured using a
halogen light curing unit for a period of 40 s.19 A ‘flat’ occlusal
morphology was established in each case and Fig. 1 provides
an example of a trial splint as described above.
Patients were requested to ‘bite down’ on to the splint and
verbally questioned about a possible reduction in their
symptom of pain on chewing/release. Where there was an
alleviation of symptoms the occlusal splint was removed with
a view to placing an adhesively bonded direct composite
splint restoration. Where there was no alleviation in the
symptoms described further diagnostic investigations were
undertaken. For cases where an improvement in the
symptoms was reported but intolerance expressed, treat-
ment was then provided according to established previously
documented protocols10–15 in a conformative manner (so
as to not involve an alteration of the position of maximum
inter-cuspation).
For each patient a careful assessment of the eruptive
potential was also carried out. Where the application of a
restoration in a supra-occlusal position may have been either
unpredictable (such as amongst cases with reduced eruptive
potential) or where the placement of a supra-coronal restora-
tion be deemed potentially detrimental to the patients oral
health, DCS restorations were not advised. A reduced eruptive
potential has been associated with patients who may present
with anterior open bites, dental implants, fixed bridgework,
bony ankylosis, and severe class III malocclusions26 and
amongst those with prominent bony exostoses.

Fig. 1 – (A) Above – an example of a ‘trial’ DCS restoration in situ – to serve as a diagnostic adjunct – note the extension of the
restoration beyond the external line angles of the tooth, onto the axial walls. In this case the patient reported complete
absence of symptoms on biting and release on the trial DCS. Subsequent restorative outcome is seen in Fig. 4. (B) Below –
view of the fit surface of the restoration.

Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
JJOD-2252; No. of Pages 10
4 journal of dentistry xxx (2014) xxx–xxx
Similarly, patients where there may be underlying condi-
tion(s) such as active periodontitis, temporomandibular joint
pain dysfunction syndrome or for those patients who may
have received prior orthodontic therapy, where the placement
of restorations in supra-occlusion may indeed lead to an
exacerbation of the underlying condition(s) or destabilisation
of the occlusal scheme established then therapy by the means
of a supra-coronal restoration was not considered suitable.
Long cone periapical radiographs were also taken of
suspected teeth to exclude the presence of unfavourable root
morphology, unfavourable crown to root ratios, the presence
of peri-radicular pathology or any signs of internal or external
root resorption. A six-point periodontal assessment of each
affected tooth was carried out using a Williams Probe.
Prior to the application of the DCS the temporomandibular
joints and associated musculature were checked. Occlusal
contacts in the intercuspal position and during movements
were identified using articulating paper and noted; an exercise
carried out as part of a routine examination amongst each of
the involved assessors. Occlusal contacts in the intercuspal
position were further identified using 8 mm thickness articu-
lating foil (Shimstock, Hanel), and documented. A record was
also made of the restorative status of the tooth as well as an
assessment of the opposing dentition.
All patients that were provided DCS restorations were
advised of the risks of intolerance, exacerbation of symptoms,
increased mobility of the affected and antagonistic tooth,
fracture(s) of the restoration, antagonistic tooth and affected
tooth, difficulties with speech, food stagnation, mastication
and the risk of developing signs and symptoms of TMJ pain
dysfunction syndrome.
Having obtained patient approval, affected teeth were
cleansed with slurry of pumice applied with a rubber cup.
Isolation was achieved by the use of cotton wool rolls and
suction. Placement of the bonded DCS restoration was carried
out as described by Banerji et al.,19 37% Orthophosphoric acid
gel was applied to the affected tooth over the occlusal and
axial walls for 30 s. Optibond Solo Plus (Kerr, Italy) a two-step
combined primer/bonding agent dentine adhesive was ap-
plied according to the manufacturer’s recommendations over
the etched surfaces. Resin composite (Gradia Direct, GC, Shade
PA2) was dispensed from a compule in increments of 1.0 mm,
to attain a final material thickness of 1.0–1.5 mm. Each
increment was contoured to approximately follow the
anatomical outline of the affected tooth, and each increment
cured for a period of 40 s. Resin composite was therefore
placed not only over the occlusal surface but also along one-
third of the axial walls. Restorations were then coated with a
layer of glycerine and post cured for a period of 40 s.
Excess resin composite was generally removed with the aid a
fine needle-shaped composite finishing diamond bur in a high-
speed hand-piece. Restorations were finished using a sequence
of dental polishing stones; a green dental stone followed by a
white stone (Durastone, Shofu Inc., Kyoto, Japan). Inter-proximal
excess was removed with the aid of hand-held inter-
proximal separating strips (West One Dental) to make sure
inter-proximal contact areas were amenable to dental flossing.
Fig. 2 provides an example of a lower second molar, which
has been affected by an incomplete fracture. The tooth has
been managed by the application of a DCS restoration.
Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
Occlusal contacts were checked using articulating paper.
Where the application of the DCS rendered the affected tooth
to be in contact during mandibular lateral excursive and
protrusive movements resin composite was added to the
guiding tooth to avoid non-axial loading of the splint,
frequently referred to in the literature as a ‘canine riser’ or
‘Stuart lift, as described by Murray et al.27 An example is
shown by Fig. 3.
Patients were recalled after a period of 2 and 4 weeks;
however all recipients of DCS restorations were informed to
contact their respective dental operators in the event of any
concerns, such as an exacerbation of their symptoms or
intolerance. At the review appointments all patients were
verbally questioned about a possible alleviation of their
symptoms of pain on chewing (or release) and hypersensitivi-
ty to cold. Patients were also asked about their tolerance to the
above approach. Restorations were assessed to confirm
structural integrity and teeth assessed for signs of tooth
mobility.
Following a period of a further 3 months (12 weeks) post-
operative, all cases received a third review (where there had
been no reason to halt treatment at a first recall stage). Bite
tests and cold tests were repeated with the aid of a Tooth
Slooth device and Endo Cold-Spray. The structural integrity of
the DCS was also re-assessed. Occlusal contacts in the
intercuspal position and on excursive and protrusive man-
dibular movements were checked and documented. Shim-
stock Foil of 8 mm thickness was used to verify the re-
establishment of occlusal contacts in the inter-cuspal
position.
3. Results
Of the 151 patient’s included in this audit 37.7% were male
patients and 62.3% female. The mean age of the sample was
50.5 years, with a range of 30–80 years.
A further 11 patients had been diagnosed positively with
CTS with the aid of the DCS restoration prior to adhesion but
had declined the placement of a supra-occlusal restoration.
Ten of the latter were male and were subsequently excluded
from the audit. Seven of these patients were managed by the
placement of a directly bonded resin onlay restoration, one by
a Type III adhesive gold onlay restoration and the remaining
three immobilised by the means of full coverage crown
restorations.
As depicted in Table 2 the most frequently affected teeth
by the condition were mandibular first molar teeth, account-
ing for 29% of the sample. Maxillary first molar teeth, followed
by mandibular second molars, maxillary second molars,
maxillary first molars, maxillary second premolars, mandib-
ular second premolars, mandibular first premolars and
maxillary third molars were affected in descending order.
There were no mandibular third molars encountered in the
sample. Overall, 45% were maxillary teeth and 55% were
mandibular.
When considering the restorative status of the 151 teeth,
113 (74.8%) had restorations present. Additionally, canine riser
restorations had been provided for 19 of the cases (12.6%) of
the sample.
JJOD-2252; No. of Pages 10

journal of dentistry xxx (2014) xxx–xxx 5

Fig. 2 – Lower right second molar with an incomplete fracture (a). A DCS restoration has been applied in supra-occlusion,
without any tooth preparation following reporting of complete symptom relief with a trial DCS (b). The restoration is free of
contact in lateral excursive and protrusive mandibular movement. Guidance has been provided by the contact between the
maxillary lateral incisor and mandibular canine tooth (c). Two months post splint placement – note the re-establishment of
occlusal contacts, verified using shimstock foil (Hanel) (d). Following successful resolution of symptoms, the DCS
restoration has been removed and the residual interocclusal space used to place a definitive direct resin composite onlay
restoration using rubber dam isolation (e). Definitive restoration – 2 years post op (f).

Fig. 3 – An example of a canine riser. Resin composite has been added to the maxillary canine to provide disclusion of the
posterior teeth upon dynamic mandibular movements, where tooth wear taking place at this tooth has culminated in the
loss of canine guidance. Note – there has been no alteration of the occlusal vertical dimension. Left – pre-op; Right post-op
view.

Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
JJOD-2252; No. of Pages 10

6 journal of dentistry xxx (2014) xxx–xxx

Table 2 – Summary of the distribution of posterior teeth in the sample, affected by incomplete fractures.
Teeth affected Number of cases % Of sample Frequency of presentation
Maxillary third molars 1 0.66% 9
Mandibulat third molars 0 0.00% 10
Maxillary second molars 13 8.61% 4
Mandibular second molars 29 19.21% 3
Maxillary first molars 33 21.85% 2
Mandibular first molars 44 29.14% 1
Maxillary second premolars 9 5.96% 6
Mandibular second premolars 8 5.29% 7
Maxillary first premolars 12 7.94% 5
Mandibular first premolars 2 1.34% 8

Table 3 – Overall success of DCS restorations to treat CTS at 2-week, 4-weeks and 3-month recall intervals.
Criteria Recall interval

2 week 4 week 3 month

Overall successful cases 133 (88.07% 131 (86.7%) 131 (86.7%)
Overall failed cases (treatment terminated) 18 (11.93%) 20 (13.3%) 20 (13.3%)

Total cases 151 (100%) 151 (100%) 151 (100%)

As illustrated by Table 3 an overall success rate of 86.7%
was determined for the complete resolution of the signs and
symptoms of CTS within 3 months of restorative intervention
with a DCS restoration. Only one patient had persistent
symptoms of mild pain on biting at this point of recall
(Table 4); however, interestingly there had been a failure for
occlusal contacts to be completely re-established within the
time frame of 3 months of recall for this given case. The latter
patient had however reported an overall improvement,
whereby the detriment caused by post-restorative symptoms
was considerably less than that perceived prior to the
application of the supra-coronal splint and was willing to
persist with the restoration in situ. This case was classified as
being ‘successful’ as there was no pain on biting as elicited
with a bite test.
Of the initial 151 cases included (which satisfied the
selection criteria), 20 patients were excluded between the
point of placement of the restorations and the 3-month recall
period. For each of the latter, treatment was terminated.
Overall 16/20 cases were aborted as a consequence of there
being a lack of alleviation of the symptoms of pain on biting
(or release) and thermal sensitivity, or indeed, where there
has been an exacerbation of the pre-operative symptoms. Of
the latter 16 patients, 11 had developed signs and symptoms
of irreversible pulpitis, while five patients had returned for
remedial attention with progression to a complete fracture
involving the periodontal tissues. The majority of the patients
who presented with pulpal or periodontal complications
following the application of the DCS restoration had returned
and were identified within the first 2 weeks of placement.
When considering the placement of a posterior restoration
in supra-occlusion, (excluding patients where further treat-
ment had been terminated due to further pulpal or periodontal
involvement, and those which failed to fulfil the exclusion and
inclusion criteria respectively), only 4/135 patients reported an
intolerance to the restoration with an overall acceptability of
97% (131/135) as seen in Table 3. As noted above, each of the
latter cases also returned within the first 14 days of placement.
Fracture immobilisation was subsequently performed in a
manner where there was confirmation of the pre-existing
occlusal scheme; three cases received full coverage crowns
and one case a direct resin onlay. No short-term detrimental

Table 4 – Complications by cause amongst successful cases, at the 2-week, 4-week and 3 month review stage.
Symptom/problem encountered/cases by number 2 Weekly recall Further Further
4 weekly recall 3 month recall
Difficulty with chewing 94 1 0
Signs/symptoms of TMD 1 0 0
Lisping/difficulty with speech 1 0 0
Restorative failure/de-bonding, chipping, 13 (all replaced or repaired) 0 0
complete fracture/wear
Increased tooth mobility 3 0 0
Increased thermal sensitivity 0 0 0
Mild pain on biting 1 1* 1*
Note: Some patients experienced more than one complaint.
*
Occlusal contacts not re-established at 3 month recall.

Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
JJOD-2252; No. of Pages 10
journal of dentistry xxx (2014) xxx–xxx
Table 5 – Table to show the resolution of occlusal
contacts at the 3-month recall.
Cases* Occlusal contacts
Re-established Not re-established
at 3-month recall
131 (100%) 128 (97.7%) 3 (2.3%)
*
Cases lost due to pulpal and periodontal involvement at 3-month
recall period have been excluded.
effects were however reported following the initial prescrip-
tion of a less biologically invasive approach.
Pre-restorative occlusal contacts were re-ascertained in the
remainder of the sample within a period of 3 months amongst
128 of the 131 (97.7%) following the placement of the DCS
restoration (Table 5).
As shown in Table 4, of the 131 cases which reported a
complete resolution of the symptoms of CTS following a 3-
month recall, 70.6% did report difficulty with chewing where a
supra-corornal restoration had been placed within the first 2
weeks of placement. However, at the 4-week reassessment,
only one patient (of the previous 94) had returned with this
opinion, which had resolved at the 3-month recall. While
initial concern with the lack of masticatory efficiency was the
most predominant short-term complaint expressed, only one
patient had reported difficulty with speech (whereby they had
developed a lisping tendency) and one had presented with
signs and symptoms of temporomandibular joint pain
dysfunction syndrome, both cases had reported an improve-
ment in these symptoms at the 4-week recall (Table 4).
Thirteen patients (9.7%) had returned within the first 2
weeks of DCS placement requiring remedial attention where
there has been either a complete fracture, de-bonding or
minor chipping of the plastic based direct resin based
restorations (Table 4). Restorations were replaced or repaired
accordingly and each of these cases was deemed successful at
the 3-month recall interval where the restorations were
shown to be functionally satisfactory with a complete
resolution of their symptoms of CTS. Only 2.2% of the initial
sample (3/135) were shown to display signs (or symptoms) of
increased initial tooth mobility (when compared to the pre-
restorative status) following the placement of the DCS;
however each of the latter cases demonstrated no adverse
signs or symptoms at the 3-month recall following the re-
establishment of pre-restorative occlusal contacts.
Pearson Chi-squared tests were carried out on the data
relating to the gender of the sample, symptoms of intolerance,
difficulty with chewing and the complete resolution of
occlusal contacts following the placement of a DCS restoration
respectively. Using a 2 way table upon which measures of
association were computed as a constant, no measures of
association were determined following the cross-tabulation of
each of the aforementioned variables.
4. Discussion
In this present audit just under twice as many female
patients were diagnosed as suffering from CTS. A ratio of
Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
7
approximately of 2:1 (female to male) was reported in a
previous epidemiological investigation.1 This disparity not a
consistent finding28,29 but may be accounted for by a lesser
tendency for male patients to report symptoms.1 Patients in
this audit were included in a purely random manner.
The mean age of the patients affected by CTS in this sample
was 51 years, with a range of 30–80 years. As patients are
retaining their teeth into older age it is not unreasonable to
observe patients being affected by CTS in their more advanced
years than has been reported by previous epidemiological
studies.30,31 Approximately three-quarters of the teeth affect-
ed by incomplete fractures contained restorations which may
have weakened the tooth.32
Mandibular first molars were most frequently noted to be
affected by CTS which has been reported by others.33 It has
been suggested that the ‘wedging effect’ imparted by the
prominent mesio-palatal cusp of the maxillary first molar onto
mandibular first molar teeth, increases the predilection of the
latter towards fracture.30
An overall success rate of 86.7% was reported for the DCS
resin onlay restoration for the complete resolution for the
symptoms of CTS. Each of the operators were however very
familiar with the protocol published in 2010.19 The high level
of reported success is comparable to that reported for other
means of attaining intra- or extra-coronal fixation.10–15 The
inclusion of a control group would have added further
significance to the data recorded but is not feasible in an audit.
The DCS restorations included in this audit were only
followed up for a period of 3 months. The short time frame
was reflective of the nature of the restoration, being of a
‘provisional’ variety. However the successful resolution of
acute symptoms of CTS coupled with occlusal re-establish-
ment was attained for more than 97% of the sample within this
time frame. The authors of the present investigation had
replaced the DCS restoration with a more aesthetic or durable
definitive extra-coronal restoration by the removal of the
bonded restoration, as discussed below.
Canine riser restorations were provided in just over a tenth
of the sample. There was no correlation between failure rates
and the provision of such restorations. Generally, canine risers
were removed following the placement of the definitive
restoration but in some cases they were retained where signs
of tooth wear may have been noted on the guiding tooth.
Krell and Rivera14 have described a relatively large
proportion of cases of CTS, managed by the fabrication of
full coverage crown restorations, to require root canal therapy
within the first 6 months of evaluation. They considered that
the pulpal tissues are likely to have acquired some level of
‘distress’ or inflammation due to the presence of a pre-existing
crack, culminating in the seepage of noxious stimuli or
bacteria towards the dental pulp upon biting. It has also been
documented that the prognosis of cracked, root-filled teeth
managed by full coverage crowns remains bleak.34
The DCS restoration has the potential to serve as a
minimally invasive alternative to currently available means
for the acute and short-term management of CTS. Further-
more, definitive restorations (Figs. 4 and 5) can be applied
without the need for further subtractive tooth preparation
(other than a distinguishable preparation margin) simply
by the removal of the DCS restoration, as the required
JJOD-2252; No. of Pages 10
8 journal of dentistry xxx (2014) xxx–xxx
Fig. 4 – Left pre-op view of a lower first molar tooth with CTS. Right – post op view where a definitive directly placed resin
onlay has been used to substitute a successful DCS restoration.
intra-occlusal clearance had been attained through the
process relative axial movement, thereby alleviating the need
for further biological injury frequently cited to occur with the
prescription of full-coverage crown restorations.7,8
For the 128 cases where there was a successful resolution of
the symptoms of CTS and re-establishment of the pre-
intervention occlusal contacts full coverage crowns were
provided for 18 of these patients (14.0%), Type III adhesive gold
onlay restorations (Fig. 5) for 10 patients (7.8%), indirect resin
composite onlays for 2 cases (1.6%), conventional (mechani-
cally retained) cast gold onlays were provided for 3 cases (2.3%)
and the remaining 95 patients prescribed direct posterior resin
onlay restorations (Fig. 4) representing 74.3% of the successful
cases. Restorations were placed between 3 and 6 months of
symptomatic resolution and occlusal contact re-establish-
ment being attained. The authors intend to follow up and
document the outcome of these cases.
Brady and Maxwell35 have shown that in almost one-fifth of
all referrals made to specialist endodontists (where ambiguity
exists over the precise diagnosis of the presenting symptoms)
an eventual diagnosis of incomplete tooth fracture is made.
The DCS restoration has the potential to not only assist with
the establishment of a diagnosis of CTS but is readily
reversible. Indeed, among the small proportion of cases that
reported a poor tolerance or acceptance of a supra-coronal
restoration, no untoward short- to medium-term adverse
Fig. 5 – To show an example of a Type III gold adhesive
onlay, used to substitute a DCS restoration following
successful symptomatic management. Minimal
preparation has been required.
Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
effects had been noted as a consequence of initially prescrib-
ing a supra-coronal restoration.
Overall, 20 failures were observed amongst the initial
sample. Failures were due to either the subsequent develop-
ment of pulpal necrosis (55%), complete fractures (25%) or
intolerance (20%). It is very likely (regardless of the chosen
means of attaining appropriate immobilisation) that a small
proportion of teeth within the sample would have inevitably
progressed to have pulpal or periodontal complications. It is
impossible to have ascertained the exact extent of the crack at
the point of diagnosis. The DCS restoration may be readily
removed should symptoms persist, or indeed should subse-
quent endodontic therapy be required.
The DCS restoration also offers relative ease of applica-
tion. Many general dental practitioners may not have ready
access to copper rings or orthodontic bands,5 or indeed the
skills and knowledge to successfully place the latter. The
preparation of a tooth to receive a provisional crown for the
acute management of symptomatic, incompletely fractured
posterior teeth is not only time consuming but highly
invasive and indeed irreversible.6 Patients often have to be
recalled as it is seldom possible to undertake a crown
preparation and provide a provisional crown in the acute
scenario. Any undue delays in providing appropriate
immobilisation of a fracture may result in continued
propagation of the crack. It is also noteworthy that indirect
restorations require a provisional restoration, which has the
potential to increase the risk of pulpal complications, due to
persistent micro leakage.10
The DCS restoration can be readily and relatively rapidly
applied, particularly as little attention to anatomical contour-
ing is required. Furthermore, most dental practitioners will
have the required armamentarium at their disposal to permit
fabrication. However, the need to adhere to careful inclusion
criteria may be a limiting factor. The prescription of chair-side
CAD-CAM-fabricated onlay restorations16 for the definitive
management of CTS following acute management with a
resin-based DCS may offer further promise.
The present investigation also ascertained the efficacy for
the placement of a posterior restoration in a supra-coronal
position. According to the results of this audit a success rate of
97.7% was determined. The patient’s age and sex had little
influence on success or failures. A successful outcome in this
audit was determined by the ability of the supra-coronal resin
JJOD-2252; No. of Pages 10
journal of dentistry xxx (2014) xxx–xxx
onlay restoration to provide the effective resolution of the
symptoms of CTS and to provide the desired intra-occlusal
clearance. This enabled the provision of a definitive restora-
tion with cuspal coverage in a minimally invasive manner and
the subsequent re-establishment of the occlusal contacts.
The concept of placing restorations in supra-occlusion to
gain intra-occlusal clearance has been well documented in the
dental literature for the management of localised anterior
tooth wear.20–25 Space is estimated to have been created by a
combination of extrusive (60%) and intrusive movements
(40%) of the teeth.26 An element of mandibular repositioning of
the condyles has also been suggested to take place.20,21
The success rate determined by the outcome of this audit is
comparable with the values reported by other groups; where
supra-coronal restorations have been prescribed for the
conservative management of localised anterior tooth
wear.20–25 Each of the latter have reported success rates in
the range of 94–100%. Poor compliance with removable
prosthesis and the possible lack of stable occlusal contacts
in either centric relation or the inter-cuspal position have been
cited as common reasons for failure.20,23 The high success rate
in the present audit may be attributable to the careful pre-
operative assessment of cases. Patients who displayed a
reduced eruptive potential, or where the placement of a supra-
coronal restoration may have been detrimental or poorly
tolerated were not recommended such restorations.
Interestingly, occlusal contacts were re-established within
a relatively short period of time (3 months) following posterior
restoration placement. Historically, where restorations have
been applied in the supra-coronal position for the manage-
ment of anterior wear, mean times of between 4.6 months,20
5.9 months,23 6.2 months,22 9 months,24 and 7 months21 have
been reported as being taken for contacts to re-establish. The
comparatively short period of time within which occlusal
contacts were re-established may also be a reflection of the
relatively higher occlusal loads which may be applied in the
posterior dentition (which may be 2–4 times greater for
premolars and molar teeth respectively) when compared to
anterior teeth,36 which may indeed hasten the process of
dento-alveolar compensation.
There were only three cases where occlusal contacts were
not re-established within 3 months. However, in each of these
cases ‘partial closure’ was observed and continued compen-
satory movements may be ongoing. Interestingly, Gulamali
et al.,25 reported five patients amongst a sample of 26 treated
for localised anterior wear to only display partial stability of
their posterior occlusal contacts at a 10-year follow-up;
however, all of these cases were asymptomatic.
A surprisingly high tolerance rate (acceptance) of a
posterior supra-coronal restoration of 97.03% was recorded.
The latter may be again accounted for by the means in which
consent was obtained and the application of clinical criteria
before a DCS was used. Similarly high levels of patient
acceptance have been described by Hemmings et al.20 Diffi-
culty with chewing was a consistent feature noted in this
audit, reported by approximately 70% of the patients.
However, this complaint resolved in 98.9% of the patients
within the first 14 days post restoration. It is important that
patients are made aware of this potential effect when
obtaining consent.
Please cite this article in press as: Banerji S, et al. A multi-centred 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), http://dx.doi.org/10.1016/
j.jdent.2014.02.017
9
At the fortnightly recall one patient reported a phonetic
disturbance and another patient developed signs and symp-
toms of TMJ dysfunction. However both found these to be
transient and resolved within the first month. Analogous
results have been reported with respect to these complaints by
workers when placing anterior supra-coronal restorations.20,23
A very small proportion of patients were noted to develop
signs of tooth mobility (2.2%) following the application of a
supra-coronal restoration which returned to normal following
the re-establishment of occlusal contacts. The incidence of
external root resorption is a possible detrimental effect of
orthodontic tooth movement. There is no evidence to suggest
this would occur with the use of the supra-occlusal restora-
tions possibly due to the existence of protective inhibitory
feedback from the periodontal ligament.26
Overall, 9.7% of the sample reported with restoration
failures related to either the occurrence of a complete fracture,
de-bonding or minor chipping. All failures were readily
addressed and each case subsequently progressed to success-
ful management of CTS. Failures in the anterior region, where
restorations are placed in supra-occlusion for the manage-
ment of localised anterior tooth wear are less commonly
observed to occur.21
Failures in the posterior dentition of resin restorations
applied in supra-occlusion may however be reflective of the
inherent shortcomings of resin composite where it is applied
to areas of high occlusal loading. Indeed, Bartlett and
Sundaram37 have reported the short-term prognosis for the
use of micro-filled resin onlays for the management of
severely worn teeth to be poor. The selection of an appropriate
composite resin, the manner in which it is applied, and the use
of an appropriate adhesive system may all be factors that
require further consideration when fabricating a DCS restora-
tion. In contrast, Hamburger et al.,38 have elucidated a very
acceptable failure rate of 6.9% for 332 over a mean observation
period of 4 years for posterior direct resin composite
restorations for the treatment of severe tooth wear at an
increased occlusal dimension using a hybrid composite resin
(versus a microfilled variety). A similar prognostic outcome
was described by Attin et al.,39 for analogous restorations
applied for the treatment of erosive worn dentitions when
observed for 5.5 years; however, marginal deterioration and
discoloration and some loss of surface texture was reported.
5. Conclusion
This audit has provided evidence to support the use of a direct,
resin composite onlay coronal splint (applied in supra-
occlusion) as a minimally invasive alternative to conventional
protocols for the diagnosis and management of symptomatic,
incomplete posterior tooth fractures. This form of restoration
may be readily applied (and removed), offering contingency
planning with little financial cost being incurred. However,
careful case selection is paramount. Evidence has also been
provided for the predictable use of posterior restorations
placed in supra-occlusion, provided a meticulous pre-opera-
tive assessment of the eruptive potential and dental health is
carried out. Patients are likely to suffer with transitory
difficulty with chewing and should be consented accordingly.
JJOD-2252; No. of Pages 10
10 journal of dentistry xxx (2014) xxx–xxx
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