Cracked tooth syndrome.

in brief
• Updates and clarifies the definition of

Part 1: aetiology and diagnosis the term ‘cracked tooth syndrome’,

PraCtiCe
including an overview of the typically
associated signs and symptoms of this
syndrome complex.
S. Banerji,1 S. B. Mehta2 and B. J. Millar3 • Provides an account of the epidemiology,
aetiology and diagnosis of the condition,
including a description of available special
Verifiable CPD PaPer clinical tests to form a positive diagnosis.
• Details the factors which may influence
the prognosis of affected teeth.

Symptomatic, incompletely fractured posterior teeth can be a great source of anxiety for both the dental patient and den-
tal operator. For the latter, challenges associated with deriving an accurate diagnosis together with the efficient and time
effective management of cases of cracked tooth syndrome are largely accountable for the aforementioned problem. The
aim of this series of two articles is to provide the reader with an in-depth insight into this condition, through the under-
taking of a comprehensive literature review of contemporarily available data. The first article will provide details relating
to the background of cracked tooth syndrome including the epidemiology, patho-physiology, aetiology and diagnosis of
the syndrome, together with a consideration of factors which may influence the prognostic outcome of teeth affected
by incomplete, symptomatic fractures. The second article will focus on the immediate and intermediate management of
cracked teeth, and also provide a detailed account of the application of both direct and indirect restorations and restora-
tive techniques used respectively in the management of teeth affected by this complex syndrome.

introDuCtion ‘split tooth syndrome’ have also been

The term ‘cuspal fracture odontalgia’ was
first used by Gibbs in 1954,1 to describe a
condition which is better now known as
‘cracked tooth syndrome’ or ‘cracked cusp
syndrome’. The latter concept was coined
by Cameron in 1964,2 who proceeded to
define the condition as ‘an incomplete frac-
ture of a vital posterior tooth that involves
the dentine and occasionally extends to
the pulp’. In more recent times the defi-
nition has been amended to include, ‘a
fracture plane of unknown depth and
direction passing through tooth structure
that, if not already involving, may progress
to communicate with the pulp and or
periodontal ligament’.3
The term ‘incomplete fracture of poste-
rior teeth’ is often used interchangeably
with that of cracked tooth syndrome,4
while the terms ‘green-stick fracture’ or
1
Senior Clinical Teacher; 2General Dental Practitioner
and Clinical Teacher, 3*Professor, Consultant in Restora-
tive Dentistry, Department of Primary Dental Care,
King’s College London Dental Institute, Bessemer Road,
London, SE5 9RW
*Correspondence to: Professor B. J. Millar
Email: brian.millar@kcl.ac.uk
Refereed Paper
Accepted 25 March 2010
DOI: 10.1038/sj.bdj.2010.449
© British Dental Journal 2010; 208: 459–463
used synonymously.5
Patients suffering from cracked tooth
syndrome (CTS) classically present with a
history of sharp pain when biting, or when
consuming cold food/beverages.6 It has
been suggested that the symptom of pain
on biting increases as the applied occlusal
force is raised.7 A detailed assessment of the
symptoms may reveal a history of discom-
fort that may have been present for several
months previously. Other symptoms may
include pain on release of pressure when
fibrous foods are eaten, ‘rebound pain’.8
Pain may also be elicited by the consump-
tion of sugar containing substances5 and
also by the act of tooth grinding or during
the undertaking of excursive mandibular
movements.9 While some patients are able
to specify the precise tooth from which the
symptoms may be arising, the latter is not
a consistent feature. The absence of heat
induced sensitivity may also be a feature.
Where the fracture line may eventually
propagate into the pulp chamber (‘complete
fracture’), symptoms of irreversible pulpitis
or apical periodontitis may ensue, while
fractures which progress further towards
the root may be associated with areas of
localised periodontal breakdown or at
worst culminate in vertical tooth fracture5
fig. 1 Shows an example of a tooth with
a vertical root fracture, where the patient
initially presented with symptoms of cracked
tooth syndrome. any delays in instituting
therapy may result in such an outcome, which
may happen where there is doubt over the
diagnosis of the condition
as shown by Figure 1. Table 1 provides
a summary of the commonly associated
signs and symptoms associated with CTS.
The physiological basis of pain on chew-
ing has been hypothesised by Brannstrom
et al.10 to be accounted for by the sud-
den movement of fluid present in dentinal
tubules which occurs when the fractured
portions of the tooth move independently
of one another. It is thought that the lat-
ter results in the activation of myelinated
A-type fibres within the dental pulp,
thereby accounting for the acute nature of
the pain. It has also been suggested that the
perception of hypersensitivity to cold may
occur as a result of the seepage of noxious
irritants through the crack, which results

BRItIsh DentAl JOuRnAl VOLUME 208 NO. 10 MAY 22 2010 459

© 2010 Macmillan Publishers Limited. All rights reserved

PraCtiCe
in the subsequent release of neuropeptides
which cause a concomitant lowering in the
pain threshold of unmyleinated C-type
fibres within the dental pulp.11
An alternative hypothesis has been
proposed, whereby it has been postu-
lated that the symptoms are caused by the
alternating stretching and compressing of
the odontoblast processes located within
the crack.12
The aim of this article is to provide an
overview of the condition of ‘cracked tooth
syndrome’, with regards to its epidemiol-
ogy, aetiology and diagnosis.
Figure 2 illustrates a tooth which has an
incomplete fracture, which was revealed
upon the removal of an existing silver
amalgam restoration. An incomplete tooth
fracture is often difficult to visualise before
a restoration is removed, but transillumi-
nation can be used from different aspects
to show the presence of an interface within
the tooth (Fig. 3). Tooth fractures can be
highlighted by the use of stains although
this may be difficult to remove and colour
the final aesthetic restoration.
ePiDemiology of
CraCkeD tooth SynDrome
Epidemiological studies of the incidence of
cracked tooth syndrome are conflicting;13,14
however, it would be appropriate to state
that CTS is a condition which generally
affects adult dental patients, typically in
the age range of 30 to 60 years. While
the results of an early epidemiological sur-
vey by Cameron in 19766 seemed to sug-
gest that the condition was much more
prevalent among female dental patients,
it has since been shown by more recent
studies that both sexes seem to be equally
affected.15
Geursten et al.16 have reported that tooth
fractures are a potential major cause of
tooth loss in the industrialised world.
The availability of incidence data on the
condition of cracked tooth syndrome is
largely lacking. A study by Krell et al.17
has reported an incidence rate of 9.7%
among 8,175 patients referred to a private
endodontic practice over a period of six
years. It would be logical to assume that as
more patients are retaining their teeth into
older age incomplete fractures of posterior
teeth are more likely to be observed to be
occurring at an even higher frequency in
the future.
460
table 1 the commonly presenting signs and symptoms seen in cases of cracked
tooth syndrome (CtS)
Sudden, sharp pain on biting/chewing and in some cases on release: ‘rebound pain’
Sensitivity to cold thermal stimuli; in some cases hyper-reactivity to hot/sugary stimuli may also occur
Symptoms may be present for periods ranging from weeks to months
Inconsistent ability to localise the affected tooth
Pain may be elicited by lateral cusp pressure, as evoked by ‘bite tests’ and tooth grinding
Fracture lines may be seen clinically (sometimes upon removal of the restoration), aided by magnification,
dyes or transillumination
Positive response to vitality tests; exaggerated response to cold thermal stimuli
Radiographs; usually inconclusive
While incomplete posterior tooth frac-
tures are most likely to be seen to be occur-
ring in teeth which have carious lesions
or contain dental restorations, a study
by Hiatt 13 reported that 35% of the cases
presenting with CTS among their sample
were among teeth which were sound and
caries free. a
Mandibular molar teeth appear to be the
most commonly involved teeth by this con-
dition,13 followed by maxillary premolars
and maxillary molar teeth - while mandibu-
lar premolar teeth seem to be least affected.
It has been hypothesised that since lower
first molar teeth are usually the first per-
manent teeth to erupt into the dental arch,
they are most likely to be affected by the b
condition of dental caries, followed by the fig. 2 Shows an example of a tooth which
need of subsequent restorative interven- has an incomplete fracture (a) which
tion.14 These teeth are therefore more likely was revealed upon removal of an existing
silver amalgam restoration; (b) the arrows
to be rendered with large, deep restorations,
illustrates the path of the fracture line
making them more vulnerable to the proc- running around the mesiopalatal cusp
ess of subsequent fracture. It has also been
proposed that the ‘wedging effect’ inflicted
upon lower first molar teeth from the prom-
inent mesio-palatal cusp of maxillary first
molar teeth may also be contributory.14
aetiology of CraCkeD
tooth SynDrome
The aetiology of incomplete fractures of
posterior teeth is multi-factorial. In an
article by Guersten et al.14 it is stated that
‘excessive forces applied to a healthy tooth fig. 3 transillumination of cracked cusp
showing mesial midline and lingual fractures.
or physiologic forces applied to a weak- the transmission of the light beam has been
ened tooth can cause an incomplete frac- ‘stopped’ mesio-lingually by the presence of
ture of enamel or dentine’. the fracture
Lynch et al.18 have subdivided the causes
of cracks into four major causative cat- ‘Restorative procedures’ such as the
egories, hence: ‘restorative procedures’, placement of ‘friction lock’ or ‘self thread-
‘occlusal factors’, ‘developmental condi- ing dentine pins’,19 the non-incremental
tions’ and ‘miscellaneous factors’. application of composite resin, excessive
BRItIsh DentAl JOuRnAl VOLUME 208 NO. 10 MAY 22 2010
© 2010 Macmillan Publishers Limited. All rights reserved

hydraulic pressure when luting inlays,
onlays, crowns or bridges5 (in particular
where the restorations may be ‘tight-
fitting’), can all induce stresses onto the
residual tooth structure culminating in a
possible fracture.20 Likewise, the place-
ment of poor quality dental amalgam
alloys, the contamination of freshly placed
dental amalgam by moisture and exces-
sive condensation pressures when plac-
ing amalgam may also induce fractures.21
It is ironic, however, that dentine pins
are often used to restore fractured cusps
among teeth which have been lost through
cracked tooth syndrome.
Other aspects of ‘restorative practice’
which may contribute to crack formation
include the excessive removal of tooth
tissue during cavity preparation which
indeed has been shown to significantly
lower tooth rigidity.22 Deep cusp-fossa
relationships which arise as a result of
the over-contouring of restorations may
also contribute to the fracture of the non-
functional cusp.5 The preparation of vital
teeth to receive MOD amalgam restorations
(with the loss of both marginal ridges) has
been shown to significantly reduce rela-
tive cuspal rigidity, on average by 63%.23
It has been proposed that a cavity of width
in excess of one quarter of the intercuspal
distance should be considered to be at an
increased risk of fracture.24
Ratcliff et al.25 have estimated that the
presence of an intra-coronal restoration
can predispose the tooth to a risk of frac-
ture 29 fold times greater than that of a
healthy, un-restored tooth! Differences
in the co-efficients of thermal expansion
between that of the tooth tissue and restor-
ative material may also have the potential
to induce fracture.26
‘Occlusal causitive factors’; Trucshowksy5
has stated that the most common cause of
cracked tooth syndrome is that of ‘a mas-
ticatory accident’ - biting suddenly on a
hard object such as bone with excessive
force. Other commonly attributing food
items/objects include betel nut chewing,
inadvertent biting of lead shot, cherry
stones and ‘granary’ bread.27
Trauma from the occlusion may also
lead to fracture. Helkimo et al.28 deter-
mined the maximum biting force between
natural molars to range from 10 to 73 kg
with an average of 45.7 kg for males and
36.4 kg for females. It has been estimated
BRItIsh DentAl JOuRnAl VOLUME 208 NO. 10 MAY 22 2010
that the ratio of force on molars, premolars
and incisors is 4 : 2 : 1 respectively, with
far higher forces being applied the closer
the tooth is to its posterior occlusal deter-
minant, (the temporo-mandibular joint).29
Occlusal interferences on vulnerable cusps
can also lead to eventual fractures as may
do non-working side occlusal interfer-
ences.30 The loss of anterior guidance may
also lead to the generation of harmful
eccentric forces.
Parafunctional tooth grinding habits
may also lead to the generation of con-
siderable occlusal forces, in particular the
habit of nocturnal bruxism, possibly due
to cortical inhibitors being suppressed dur-
ing sleep, thus allowing greater forces to
be applied.31
So called ‘developmental factors’ include
the possibility of areas of localised struc-
tural weakness within a tooth, arising as
a result of the incomplete fusion of areas
of calcification.13
Morphological factors associated with
the increased risk of cracked tooth syn-
drome include deep occlusal grooves,
pronounced vertical radicular grooves or
bifurcations, extensive pulp spaces, steep
cusp angles, prominent mesio-palatal cusps
of upper maxillary first molars as well as
the presence of lingually inclined man-
dibular molar teeth, which are thought to
be the be most likely to suffer the complete
loss by fracture of both lingual cusps.32
Under the category of ‘miscellane-
ous factors’ are included factors such as
the effect of lingual barbells; the crack-
ing/crazing of tooth tissue which arises
from the use of high speed rotary instru-
ments; erosive tooth wear and the factor
of thermal cycling, which may induce
enamel cracks.
An ageing dentition may also be more
predisposed to cracking as dental hard
tissues become more brittle and less elas-
tic with age, whereby forces applied may
exceed the elastic limits of dentine.7
the DiagnoSiS of
CraCkeD tooth SynDrome
The diagnosis of cracked tooth syndrome
is often problematic and has been known
to challenge even the most experienced of
dental operators, accountable largely by
the fact that the associated symptoms tend
to be very variable and at times bizarre.33
Indeed it has been reported34 that 20% of
© 2010 Macmillan Publishers Limited. All rights reserved
PraCtiCe
patients referred to specialist endodontists
with diagnostic uncertainties are eventu-
ally diagnosed with incomplete tooth frac-
tures. The importance of an early diagnosis
has being linked with successful restora-
tive management and prognosis.35
A careful history and assessment of the
symptoms, in particular that of cold sen-
sitivity and sharp pain on biting hard or
tough food which ceases on the release
of pressure, is an important indicator.
Symptoms may vary according to the
depth and orientation of the crack.4
According to Homewood,36 fractures
tend to occur in a direction parallel to
the forces on the cuspal incline; thus with
larger restorations, cracks tend to be more
superficial and thereby produce fewer
symptoms, while with smaller restorations
cracks tend to be deeper and closer to the
pulp. It has also been suggested that most
cracks tend to run vertically (as opposed
to horizontally).33 Vertical cracks usually
run in a mesio-distal direction along the
occlusal surface and may involve one or
both of the marginal ridges respectively.33
Diagnosis is often complicated by the
fact that several other dental conditions
may readily be mis-diagnosed as cracked
tooth syndrome. Such conditions include:
acute periodontal disease, reversible pulpi-
tis, dentinal hypersensitivity, galvanic pain
associated with the recent placement of
silver amalgam restorations, post-opera-
tive sensitivity associated with micro-
leakage from recently placed composite
resin restorations, fractured restorations,
‘high spots’ or areas of hyper-occlusion
from dental restorations, occlusal trauma
from the process of parafuntional tooth
grinding, orofacial pain arising from con-
ditions such as trigeminal neuralgia and
psychiatric disorders such as atypical
facial pain.20
While occasionally cracks may be
detected by visual inspection, they are not
always readily apparent. The use of mag-
nifying loupes and trans-illumination with
the aid of a fibre-optic device (Fig. 3) may
be helpful.18 The use of a sharp straight
probe may also help detect ‘catches’ in the
cracks, while the application of the latter
dental instrument at the margins of heav-
ily restored teeth which are suspected to
be involved by an incomplete fracture
may elicit symptoms of sharp pain should
a fracture be possibly present. The removal
461
PraCtiCe
of existing restorations may also help to
reveal fracture lines.
An un-authenticated technique, which
has often been used by the authors of this
article particularly where there may be
doubt over the precise diagnosis, is one
which involves the placement of compos-
ite resin over the affected tooth without
etching and bonding; material is added
at a minimal thickness of 0.5 mm and
wrapped over across the external line
angles of the tooth onto the axial walls.
The set material acts as a splint and the
patient can bite down on this with an
intervening bite test; although high, it
may result in greatly reduced symptoms
as the fracture no longer opens on clench-
ing, perhaps confirming the diagnosis of
an incomplete fracture. It must be empha-
sised, however, that there is no evidence in
the available literature (to the knowledge
of the authors) to scientifically validate
this approach.
The use of stains to highlight fracture
lines such as gentian violet or methyl-
ene blue33 have been described by several
authors. However, it is imperative to note
that the technique of using stains to delin-
eate cracks may take several days to be
effective and may require the placement
of a provisional restoration in the cavity,
which may further undermine the struc-
tural integrity of the tooth and thereby
aid in the process of crack propagation.
Another complication with the use of
delineation dyes is the subsequent diffi-
culty associated with the placement of a
definitive aesthetic restoration. Periodontal
probing may also be helpful, as localised
isolated periodontal probing defects may
be seen where fracture lines may have
extended subgingivally.
The use of so called ‘bite tests’18 to mimic
the symptoms associated with incomplete
fractures of posterior teeth may also prove
helpful. However, it is important to gain
prior consent from the patient as the use
of such a test may cause cuspal fragmenta-
tion! Objects that have been traditionally
used for this purpose include: orange wood
sticks, cotton wool rolls, rubber abrasive
wheels such as a Burlew wheel or the head
of a number 10 round bur in a handle of
cellophane tape.
The technique for the use of wood sticks
has been described.37 It is advocated that
the stick is rested on the suspected tooth
462
and the patient asked to bite; by the sub-
sequent application of the stick to each
individual cusp in turn it may be possible
to localise the affected cusp. The use of
cotton wool rolls involves placing the roll
on the suspected tooth and requesting the
patient to bite down and then suddenly
releasing the pressure. Pain perceived upon
release of pressure has been suggested
by Kruger 38 to confirm the diagnosis of
cracked tooth syndrome. The use of rubber
plungers of anaesthetic carpules suspended
from a length of floss, to be used in a simi-
lar fashion to cotton wools rolls, to aid in
the diagnosis of cracked tooth syndrome,
has also been described.39
Commercially available diagnostic tools
to undertake ‘bite tests’ include products
such as ‘Fractfinder (Denbur, Oak Brook,
IL, USA) and ‘Tooth Slooth II’ (Professional
Results Inc., Laguna Niguel, California,
USA). Figure 4 shows the Tooth Slooth
which comprises two small plastic pyrami-
dal plastic bite blocks attached to a handle
at either end (20 by 10 mm). One block has
a small concavity at its apex which can
accommodate the cusp of a tooth.40 The
slooth is placed either between the cusps of
a tooth or onto the cusp tip and the patient
is asked to close together. Pain on biting
or release on the specific cusp identifies
the offending/involved cusp. Ehrmann et
al.37 have advocated the use of this method
as one with a higher level of sensitivity
than that associated with the use of wood
sticks; furthermore, it is thought to allow
for the more accurate identification of the
affected/involved cusp.
Vitality tests for involved teeth are usu-
ally positive,5 although sometimes affected
teeth may display signs of hypersensitivity
to cold thermal stimuli due to the presence
of pulpal inflammation; a feature that may
help to confirm a diagnosis of CTS. Teeth
affected by the condition are seldom tender
to percussion (when percussed apically).
Radiographs tend to be of limited use
as fractures tend to propagate in a mesio-
distal direction,18 parallel to that of the
plane of the film. However, they may be
of value in detecting more rarely occur-
ring fractures which may be running in a
bucco-lingual direction and for excluding
other dental pathology.20
The use of copper rings, stainless steel
orthodontic bands and acrylic provi-
sional crowns to confirm the diagnosis
BRItIsh DentAl JOuRnAl VOLUME 208 NO. 10 MAY 22 2010
© 2010 Macmillan Publishers Limited. All rights reserved
fig. 4 tooth Slooth (Professional results,
uSa)
of an incomplete fracture of a posterior
tooth, have been discussed in more detail
in second of the two articles on cracked
tooth syndrome.
the PrognoSiS of teeth
affeCteD by CraCkeD
tooth SynDrome
The prognosis of teeth affected by CTS
is dependent on a multitude of factors.
The location and extent of the crack is
a key determinant. It has been reported
that incomplete cracks generally run in a
mesio-distal direction (81.1%); rarely are
vertical or orovestibular cracks seen,41 For
cracks that are confined to the dentine
layer, that run in a horizontal direction
not involving the dental pulp, or for those
fractures which are limited to a single mar-
ginal ridge which do not extend more than
2-3 mm below the periodontal attachment,
the prognosis has been reported by Clark et
al.42 to be ‘excellent’; while the prognosis
for fractures that involve both marginal
ridges, communicating with the dental pulp
or those fractures that extend vertically
through the pulp or involve the sub-pulpal
floor has been described as being ‘poor’.
Affected teeth which present with com-
plete mesio-distal fractures, or one where
the fractured segment cannot be removed
or be exposed by gingivoplasty or by an
alveoplasty procedure, have been described
as having a ‘hopeless prognosis’.42
Other factors which may impact on the
prognosis include the anatomy of the tooth
and roots, the previous operative/restora-
tive history of the tooth and the functional
forces applied to the tooth (during both
functional and parafunctional activity).18
Early recognition will also help to pre-
vent further cracking, in particular, helping
to avoid propagation of the crack into the
pulp chamber or sub-gingivally. It has been
postulated that the loss of pulp vitality will
have a poor effect on the prognosis of the

tooth, as endodontically treated cracked
teeth have been shown to display a rela-
tively high failure rate of 14.5% after an
evaluation period of two years.43 Indeed, it
has been reported that approximately 20%
of teeth with cracked tooth syndrome will
require root canal therapy.44 The skill and
experience of the operator are also impor-
tant factors.18
Finally, the technique used to manage
the condition will also have an important
impact on the ultimate prognosis of the
affected tooth. The second paper in this
series will discuss the latter issue in con-
siderable detail.
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38. Kruger B F. Cracked tooth syndrome. Letter to the
editor. Aust Dent J 1984; 29: 55.
39. Liebenburg W H. Esthetics in the cracked tooth syn-
drome: steps to success using resin bonded ceramic
restorations. J Esthet Dent 1995; 7: 155-166.
40. Fox K, Youngson C C. Diagnosis and treatment of
the cracked tooth. Prim Dent Care 1997; 4: 109-
113.
41. Mittal N, Sharma V, Minocha A. Management of
cracked teeth - a case report. Endodontology
2007; 39-44.
42. Clark L L, Caughman W F. Restorative treatment for
the cracked tooth. Oper Dent 1984; 9: 136-142.
43. Tan L, Chen N N, Poon C Y, Wong H B. Survival of
root filled cracked teeth in a tertiary institution. Int
Endod J 2006; 39: 886-889.
44. Gutman J L, Rauskin H. Endodontic and restorative
management of incompletely fractured molar teeth.
Int Endod J 1994; 27: 364–365.
463
Cracked tooth syndrome.
Part 2: restorative options
for the management of
cracked tooth syndrome
S. Banerji,1 S. B. Mehta2 and B. J. Millar3
VERIFIABLE CPD PAPER
The second of this two part series on ‘cracked tooth syndrome’ will focus on the available methods for the immediate,
intermediate and definitive management of patients affected by this condition. Included in this article is a comprehensive
account of the relative merits/drawbacks of various restorative materials and their respective techniques of application for
the treatment of symptomatic, incompletely fractured posterior teeth.
PRINCIPLES FOR THE
MANAGEMENT OF
CRACKED TOOTH SYNDROME
It is apparent from the first article of this
series that the diagnosis of cracked tooth
syndrome can pose a major challenge to
the dental operator. It would also be fair to
state that the management of the condition
is by no means always a simple straight-
forward matter.
While it would appear that there is no
universally accepted restorative proto-
col, it is generally agreed that the aim
of restorative therapy is to immobilise
the segments of the tooth that move on
loading. The latter may be achieved in
a limited number of cases simply by the
removal of the affected cusp and restoring
the defect with an appropriate material, or
in the majority of cases by the placement
of a restoration that prevents independent
movement of the tooth segments on either
side of the crack, thereby ‘splinting’ the
tooth together.1
The process of splinting should minimise
flexure of the compromised cusp, therefore
not only aiming to alleviate the symptoms
of pain on biting but also prevent further
1,
Senior Clinical Teacher; 2General Dental Practitioner
and Clinical Teacher, 3*Professor and Consultant in
Restorative Dentistry, Department of Primary Dental
Care, King’s College London Dental Institute, Bessemer
Road, London, SE5 9RW
*Correspondence to: Professor B. J. Millar
Email: brian.millar@kcl.ac.uk
Refereed Paper
Accepted 25 March 2010
DOI: 10.1038/sj.bdj.2010.496
© British Dental Journal 2010; 208: 503–514
BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010
propagation of the crack and reduce the
ingress of bacterial microorganisms into
the dental pulp.2
Historically a plethora of different ‘forms’
of dental restorations have been advocated
to ‘splint teeth’ affected by incomplete
fractures. This paper will divide these into
four broad categories. Hence:
• Immediate
• Direct restorations placed intra-
coronally without cuspal coverage
• Direct restorations, which provide
cuspal coverage
• Indirect restorations placed intra-
coronally without any cuspal support
and indirect restorations which provide
cuspal coverage (onlays and full
coverage restorations).
The aim of this article is to review the
available literature on the above restora-
tions when used to treat cases of cracked
cusp syndrome, with emphasis placed
on the efficacy, efficiency, economic
viability and biological cost of each of
the above.
IMMEDIATE THERAPY OF CTS
It is generally accepted that the more rap-
idly a tooth with a crack is treated, the
easier it will be to avoid irreversible dam-
age. Table 1 provides a list of the pos-
sible immediate treatment options. As
an ‘immediate’ or remedial approach a
number of authors have advocated the
undertaking of occlusal adjustments upon
affected teeth, to reduce the stress on the
tooth, so as to not only prevent further
© 2010 Macmillan Publishers Limited. All rights reserved
IN BRIEF
• Includes a consideration of means available
to provide acute care for a patient
PRACTICE
suffering from cracked tooth syndrome.
• Provides a comprehensive review of the
available literature of both direct and
indirect restorations/restorative materials
to manage an incompletely fractured
posterior tooth.
• Introduces the concept of the direct
coronal splint as a novel approach for the
management of this distressing condition.
Table 1 Immediate treatment options
for CTS
Occlusal adjustment – destructive, short term
Remove segment – highly destructive
Immobilisation of segment:
Copper ring difficult and
periodontally damaging
Orthodontic time consuming,
band possibly not available
Temporary highly destructive,
crown time consuming
Direct quick, low cost, readily
composite splint available and non-invasive
crack propagation but also relieve the
associated symptoms.3
However, it has been argued that sim-
ply grinding the tooth out of occlusion
is likely to be only of limited benefit as
the tooth may still be critically stressed
by a food bolus to such an extent that
the process of flexure will still continue
on loading.4 Furthermore, occlusal adjust-
ment may not only involve the removal
of healthy sound tooth tissue, but when
undertaken without analysing the effects
on the residual dentition may also lead to
unwanted occlusal interferences elsewhere
in the dental arch.
Fox et al.5 have recommended that fol-
lowing a positive diagnosis of a cracked
tooth where a pre-existing restoration is
present, it should be removed to assess
the full extent of the fracture. Often dur-
ing this process the affected cusp may
‘splinter off’ and the remaining defect
managed accordingly.
503
PRACTICE

Where there has been no splintering off
the affected portion of the tooth, immedi-
ate immobilisation by means of an ‘imme-
diate extra-coronal circumferential splint’
may be applied. The latter may take the
form of a copper ring or a stainless steel
orthodontic band, both of which should
be tight fitting, contoured to not interfere
with the occlusion and cemented using
zinc-polycarboxylate cements.6
It is generally agreed however that stain-
less steel orthodontic bands are the pre-
ferred option, as they can be contoured
more effectively so as to inflict less irrita-
tion/damage to the gingival/periodontal
tissues. Upon review, following a period
of two to four weeks after the application
of the immediate splint, the absence of
pain has been described to indicate not
only a correct diagnosis but also success-
ful immobilisation.7 Where symptoms of
thermal sensitivity persist, endodontic
therapy may need to be considered.7 In
such cases, the splint may remain in situ
until the completion of root canal therapy
and the eventual application of the defini-
tive restoration.
While the placement of copper rings and
stainless steel bands have been suggested
way. The placement of such restorations
while effective are however, time con-
suming, biologically invasive and costly.
Furthermore, rarely in the opinion of the
authors is it possible to prepare a tooth to
receive a full coverage provisional crown
when a patient first presents with CTS on
the same appointment. It is worthwhile
noting however that any delay in institut- a
ing immediate therapy may lead to further
progression of the fracture and in the worst
scenario culminate in tooth loss as well.
A novel concept which has yet to be
fully supported by a clinical trial is the
placement of bonded composite resin
directly over the surface of the tooth to
splint across the fracture and immobi-
lise the segments (Fig. 1). The splinting
method is used by all the authors and is b
referred to as a ‘direct composite splint’
(DCS). It can be used with minimal tooth
reduction of the functional areas of the
occlusal surface but the authors now prefer
to use it as a non-invasive splint with no
tooth reduction, creating a flat splint in a
supra-occlusal position. Resin composite is
applied to a thickness of 1.0-1.5 mm over
the occlusal surface of the affected tooth,
and finished just beyond the external line c

to be a clinically effective, minimally angles of the affected tooth. The restora-

invasive and a cost effective immediate
treatment modality for teeth affected by
cracked tooth syndrome,7 in the opinion of
the authors, the technique of placing the
latter may be time consuming and techni-
cally challenging. Furthermore, with the
advent of adhesive dentistry, many dental
operators may not have acquired the tech-
nical experience needed with the place-
ment of copper rings; indeed, copper rings
may not always be readily available in the
modern general dental practice. Likewise,
many general dental practitioners may
not have the technical expertise or ready
access to stainless steel orthodontic bands.
Discomfort associated with the application
of copper rings and their tolerance may
be other complicating factors. In addition
patients may object to the aesthetics where
the band is visible.
The preparation and placement of full
coverage acrylic provisional crowns has
been described by Gutherie et al.8 as a
predictable, ‘immediate splinting’ option
for the management of incompletely frac-
tured teeth. Preformed crowns of differing
varieties may also be applied in a similar
tion should be contoured to display the
absence of occlusal contacts in either lat-
eral or protrusive mandibular movements
(which may require the addition of resin
composite to guiding teeth).
The above approach of placing a res-
toration in supra-occlusion follows the
principles of the well documented Dahl
concept 9-11 whereby it would be expected,
in cases other than those with limited erup-
tive potential, that through the combined
process of dento-alveolar segment intru-
sion and extrusion respectively, occlusal
contacts would be re-established after a
suitable period of time.
A DCS has the potential, in theory, to be
used as both an immediate and intermedi-
ate restorative option. It has the potential
of being biologically conservative, aes-
thetic, efficient to apply, reversible and an
inexpensive restorative modality, which
also offers the potential to offer imme-
diate pain relief and assist in diagnosis
(particularly where there may be doubt).
However, careful case selection and the
attainment of patient consent are very
important factors to consider. A detailed
d
Fig. 1 A tooth with amalgam restoration
and a mesial crack (a). Air abrasion was
used to augment micro-mechanical
retention (b) and a direct composite
splint was placed in supra-occlusion (c)
without any tooth preparation which is
designated as an immediate option for the
management of an incompletely fractured,
symptomatic lower right second molar
tooth. (d) demonstrates the importance
of ensuring that the splinted tooth is free
of occlusal contact on mandibular lateral
excursive movement
literature review has been published by
Poyser et al.12 documenting the principles
of the Dahl concept.
A DCS may also be used before the
application of an adhesive onlay (Fig. 2),
where the desired inter-occlusal space for

504 BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010

© 2010 Macmillan Publishers Limited. All rights reserved

 PRACTICE

the definitive restoration may be accom-

plished by the process of controlled intru-
sion and extrusion of the dento-alveolar
segments. The application of DCS restora-
tions does however require considerable
further research to validate its application
in every day dental practice.

THE USE OF DIRECT/PLASTIC c

INTRA-CORONAL RESTORATIONS
(WITHOUT CUSPAL COVERAGE)
TO TREAT CASES OF CTS
Dental amalgam
(conventional/bonded)

Dental amalgam, composite resin and

glass-ionomer cements are among three
of the most commonly used plastic, direct
restorative materials in contemporary den-
tal practice. In principle, their use intra-
coronally in the management of cases of
CTS (in the absence of any splintering) is
based on their ability to attach themselves
to the areas of tooth tissue located either
side of the fracture and thereby prevent
independent movement of either fragment
upon loading. In doing so, it would be
hoped that these materials would restore
the fracture strength of the tooth equiva-
lent to that of a sound caries free tooth.13
Longitudinal studies on the performance
of extensive amalgam restorations have
confirmed amalgam’s success as a direct,
plastic restorative material.14,15.However,
the fact that dental amalgam lacks intrin-
sic adhesive potential would infer that it
would have little effect on ‘binding’ frac-
tures or restoring fracture resistance unto
teeth affected by CTS (without the need of
auxiliary retentive aids).
It has been shown that fresh dental
amalgam can be bonded to etched enamel
and dentine with an ‘adhesive liner’,16
hence the concept of the ‘bonded amal-
gam restoration’. Two case reports have
been published involving the successful
application of bonded amalgam restora-
tions for patients presenting with CTS.
The first, a single clinical case involving
the use of ‘Amalgabond’;17 the adhesive
agent present in Amalgabond contains
4-META (4-methacryloxylethyl-trimelli-
tate anhydride). 4-META has been shown
to have the capacity to bind with colla-
gen fibrils present in the organic compo-
nent of dentine and to metallic ions.18 The
second case report included four patients
a d
b
suffering from CTS that had been managed
by the application of bonded amalgam
restorations, bonded using Panavia EX
(Kuraray, Japan).19
Panavia EX is a chemically active resin
that bonds to both enamel and metal.20
Bonds strengths of 8.8-14.2 MPa have
been reported to develop between etched
enamel and Panavia EX,19 versus that of
18-20 MPa between composite resin and
etched enamel.
In vitro studies have reported the fracture
strength of molar teeth containing bonded
amalgam MOD restorations to be signifi-
cantly higher than when compared to con-
ventional MOD amalgam restorations.21,22
Directly bonded resin composites
Composite resin offers an aesthetic alterna-
tive to silver amalgam for the restoration
of posterior teeth. Figures 3-6 illustrate
Fig. 2 An example of a case where a
fractured tooth (a) is treated initially with
a provisional direct supraocclusal splint
shown in (b) before the definitive gold
adhesive onlay has been placed, initially in
supra-occlusion, and now shown at three
month review where the occlusal contacts
have re-established (c, d)
examples of direct composite resin used
to restore fractured teeth. In Figure 3 con-
ventional tooth reduction was carried out
before composite placement. Figures 4 and
5 show cases where only minimal reduc-
tion was carried out and the composite
was placed at the original vertical dimen-
sion. Figure 6 shows a similar case with
no occlusal reduction where the composite
resin was placed in supra-occlusion.
The results of in vitro studies regarding the
ability of resin composite to restore cuspal
stiffness are conflicting in outcome; while
some have reported little marked improve-
ment23 others have shown that the place-
ment of composite resin restorations has the
potential to restore fracture strength, and in
some cases to a level superior to that of a
healthy, un-prepared tooth.24
Opdam et al.25 investigated the short term
clinical efficacy of bonded (direct) composite

BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010 505

© 2010 Macmillan Publishers Limited. All rights reserved

PRACTICE

a d

Fig. 3a Illustrates the same case as in

Figure 1 and is an example of a tooth
with CTS which has been managed by
the means of a direct resin composite
onlay and a conformative approach. (b)
illustrates the case immediately post-op
and (c) is three years post-operatively
resin when placed intra-coronally for the
treatment of 21 painful, cracked teeth. The
authors concluded that direct composite resin
restorations without cuspal coverage can be
effective in treating cases of CTS (75% of
cases reported alleviation of symptoms when
verbally questioned). Opdam et al.26 have
also published a report in 2008, document-
ing the results of a seven year evaluation of
the efficacy of direct composite resin when
used to restore painful cracked teeth (pre-
viously containing amalgam restorations).
The results of the latter study displayed an
annual failure rate of 6%.
It has been postulated that in the absence
of cuspal coverage, repeated loading of the
restoration or residual tooth tissue may
stress the ‘adhesive layer’ and ultimately
lead to its breakdown, with the concomi-
tant failure of the ability of the restoration
b e
c direct placement supraocclusal restoration
to effectively splint the tooth.26 The latter
effect may be exaggerated in cases of CTS
by two factors; firstly, CTS is often seem
among patients who display parafunctional
grinding habits who would be more likely to
apply higher loads to the restored tooth, and
Fig. 4 Illustrates an example of a tooth
with amalgam restoration and cusp
fracture (a). Following the removal of
the existing amalgam restoration (b)
the fracture line is visible (see arrows),
the occlusal surface has been reduced
by 0.5 mm and a bevelled finish applied
circumferentially (c). Resin composite has
been applied using an incremental ‘build-up
technique’ (d). A pre-operative silicone
matrix can also be used to fabricate the
occlusal anatomy of the restoration. A
(DCS) has been placed in supra-occlusion
with minimal tooth preparation, which may
be retained as an intermediate restoration
in the short to medium term (e)
secondly due to the presence of a pre-exist-
ing fracture, cuspal flexibility would have
already been increased when compared to
a healthy un-fractured, sound tooth, plac-
ing further greater strain on a progressively
weakening adhesive layer.

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 PRACTICE

It has been reported that resin bonded

composites (and bonded amalgam restora-
tions) are less effective in restoring fracture
resistance where cavities are greater than
half of the intercuspal width (without the
use of cuspal coverage).23 The incremental
application of composite resin to a cav-
ity (versus bulk placement) also has a sig-
nificant impact on improving the ultimate
fracture resistance of a restored tooth.27
Polymerisation shrinkage is a factor
commonly cited as an important cause for
the higher reported failure rate associated
with large composite resin restorations.28
Shrinkage may also cause the flexion of
the cusps towards the bulk of the material
which may further accentuate the fracture,
a c
and also induce stresses in the material
and the adhesive layer, which would in
turn lead to the failure of the ability of the
material to immobilise the crack.
The feature of polymerisation shrink-
age may, however, be vital to the suc-
cess reported for direct resin composite
onlays, as it may help to splint the crack by
effectively embracing the cusps together,
d
as polymerisation shrinkage will cause
the material to shrink towards the cen- Fig. 5 Amalgam removed (a) and tooth
tre of the restoration and add up to the prepared with minimal cuspal reduction
(b), then restored with direct composite
bonded surface.29
resin (c) at correct occlusal height and at
Other factors which should also be taken review (d)
into consideration when considering the
application of resin composite in poste-
b
rior teeth include, the risks of restoration
bulk fracture and accelerated wear. The
attainment of high quality proximal con-
tact points and occlusal anatomical form (cermets), however, have been reported to complete a complex composite resin res-
may also be a concern when using direct restore prepared teeth to a strength equiva- toration compared to similar amalgam res-
composite. lent to that of sound teeth or those restored torations,33 it still takes less time than to
with resin composite.31 The poor aesthetics complete an indirect restoration. All too
Glass ionomer cements (GICs) associated with cermets is a concerning often, where a patient has had to return
The role of glass ionomer cements (GICs) in factor. following a diagnosis of an incomplete
the management of cases of incompletely GICs may have a role to play in the man- fracture for the preparation of an indirect
fractured posterior teeth to the knowledge agement of cases of CTS as base materi- restoration, the fracture may have pro-
of the authors has not been extensively als under extensive direct composite resin gressed to the pulp or culminated in the
documented. It has been suggested that fillings thereby reducing the volume of loss of an extensive amount of the tooth.
while GICs have the capacity to increase resin required and the associated levels of According to a leading authority,
tooth stability among teeth with class polymerisation shrinkage.32 cracked teeth should be considered to be
II posterior cavities, they offer a lower In summary, direct plastic restoratives at an increased risk of pulpal complica-
bond strength to both enamel and den- (bonded amalgam and resin composite tions (in particular, where there has been
tine when compared to resin composite.30 restorations), when applied without cus- thermal sensitivity);26 the preparation of
Furthermore, due to their inferior wear pal coverage to manage cases of cracked such teeth to receive indirect restorations
and fatigue properties (compared to silver tooth syndrome, have the potential to would not only result in the loss of more
amalgam and composite resin), they are provide a conservative, cost effective and sound tooth tissue but necessitate the use
not the first choice of material for applica- time efficient option to the use of indirect of a provisional restoration. Both the lat-
tion in stress bearing posterior cavities.30 alternatives. While it has been proposed ter factors will increase the risk of pulpal
Silver reinforced glass ionomer cements that it takes 2.5 times longer to place and complications.

BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010 507

© 2010 Macmillan Publishers Limited. All rights reserved

PRACTICE
a b
Fig. 6 A cavity showing amalgam removed and crack visible (see arrow) on distal margin (a). The tooth was restored without cusp reduction
and directly placed composite as a supraocclusal composite splint. (b) shows immediate post-op view and (c) is three years post op
It has been reported by Gutmann et al.34
that approximately one fifth of all teeth
diagnosed with cracked tooth syndrome
will eventually require endodontic ther-
apy; furthermore the prognosis of endo-
dontically treated, cracked teeth appears
to be relatively poor. A study by Tan et
al.35 reported a failure rate of 14.5% for
cracked, root filled teeth after a relatively
short evaluation period of just two years.
Caution does need to be exercised when
considering the use of either direct bonded
amalgams or resin composites for cavities
which are greater than half the intercuspal
width in cases of CTS,23 and perhaps among
patients who display signs of bruxism.
DIRECT RESTORATIONS
WITH CUSPAL COVERAGE;
DIRECT OVERLAYS/ONLAYS
Direct amalgam overlays
(conventional/bonded)
36
Hood et al. in 1991 reported that teeth
restored with amalgam overlays had ‘frac-
ture energies equivalent to that of intact
teeth’. Accordingly, Homewood37 has advo-
cated the overlaying of the cusps of teeth
affected by CTS as a primary mode of
treatment for such cases. The latter under-
took an analysis to assess the perform-
ance of conventional amalgam overlays
for the management of cases with CTS,
and reported a very high success rate (in
excess of 93%).37
Davis et al.38 have also published the
results of a clinical study to compare the
efficacy of conventional pin retained
complex amalgam fillings versus bonded
amalgam restorations. A similarly high
proportion of cases displayed resolution
of symptoms as reported by Homewood.37
Interestingly, the results of the study by
Davies et al.38 showed a further reduction
508
in cold sensitivity was observed to occur in
the group treated by the means of bonded
amalgam overlays following a two week
post-operative period (while the baseline
levels for thermal sensitivity remained
unchanged for the non-bonded group). The
latter observation may be accounted for by
the ability of the resin liner to seal patent
dentinal tubules, but also by the fact that
the non-bonded group required 4 mm of
tooth reduction of the involved cusp (to
accommodate the pin[s]) as opposed to 2
mm for the bonded group, which may have
made a difference in the pulpal response
to cold.
The results of both studies37,38 have indi-
cated a possible role for amalgam over-
lays in the management of incomplete
fractures in posterior teeth (at least in the
short term), particularly where a bonded
amalgam restoration is applied.
Directly bonded resin
composite onlays
According to the results of an in vitro
study, where premolar teeth were assessed
for fracture resistance where composite
resin restorations had been placed both
with and without cuspal coverage, cases
with cuspal coverage displayed a signifi-
cantly higher fracture resistance.39
The above was reflected in two clinical
studies by Opdam et al.25,26 In both stud-
ies, following the removal of the existing
amalgam restoration, the cusps of affected
teeth (as opposed to the entire occlusal sur-
face) were reduced by 0.5-1.0 mm coro-
nally from the onset of the micro-crack
and the resulting cavity outline finished
with a bevelled margin (before the applica-
tion of direct composite resin).
In the more recent of the two studies,
cases that were included were evaluated
for a period of six to seven years.26 At the
BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010
© 2010 Macmillan Publishers Limited. All rights reserved
c
end of the observation period, a survival
rate of 100% was elucidated; all 21 cases
reported the elimination of symptoms of
thermal sensitivity and pain on biting
when asked verbally. Similar results were
published by Homewood.37
The application of resin composite over
the affected cusp in cases of CTS appears
to reduce the stress on the weakened cusp,
possibly by a combination of factors such
as composite resin itself having some level
of ‘shock absorbing effect’25 by increas-
ing cuspal stiffness and by re-distribut-
ing occlusal loads away from the crack
towards the axial walls and down the long
axis of the tooth. A reduction in the height
of the affected cusp may also reduce its
level of flexion upon loading, which may
also help in the management of symptoms
but also reduce the stress on the adhesive
layer, and thereby enhance the longevity
of the restoration.
Figure 3 shows an example of a tooth
with CTS, which has been managed by the
means of a direct resin composite onlay
and a conformative approach. Figure 3c
has been taken of the same restoration,
three years post-operatively.
A success rate of 72.7% has been
reported for teeth restored by means of
direct composite resin inlays/onlays (over
a period of 11 years); fracture, occlusal
wear and secondary caries were the prime
causes of failure.28 However, Bartlett et al.40
have contraindicated the use of direct (or
indirect) composite resin for the treatment
of worn posterior teeth.
In summary, it would appear that the
use of plastic materials (bonded amalgams
and bonded resin composite) when placed
over the affected cusp in cases of cracked
tooth syndrome seems not only to be time
and cost effective but also clinically suc-
cessful in the alleviation of associated

symptoms. Further studies are however
required to assess the long term efficacy
of bonded amalgams in cases of CTS.
Pulpal involvement does not appear to be
a major issue either where direct overlays
have been applied to manage CTS, which
is a concern where indirect methods are
used. Should endodontic therapy, however,
be required where a plastic direct mate-
rial has been applied, the cost implications
are minimal and access to the pulp would
be relatively straightforward, as opposed
to in the presence of an indirect casting,
which may need to be re-fabricated fol-
lowing the completion of root canal ther-
apy (while the direct restoration may be
readily repaired).
The prime concern with the applica-
tion of direct overlays is the level of tooth
reduction, the need for considerable opera-
tor skill and the longevity of these restora-
tions, particularly among bruxists.
INDIRECT RESTORATIONS
Inlay restorations
(conventional and adhesive)
Conventional intra-coronal inlay restora-
tions utilise the concept of ‘wedge reten-
tion’, which has the potential of exerting an
outward pressure on the tooth.41 Pressure
may be exerted not only upon trial of the
restoration (pre-cementation) but also dur-
ing its functional lifespan, where cyclical
occlusal loads are applied. Consequently,
conventional inlays have absolutely no
role in the treatment of cases of CTS.
With an increase in the demand by den-
tal patients for more aesthetic, predict-
able posterior tooth restoratives, ceramic
inlays and indirect composite inlays have
become commonplace in contemporary
dental practice as an alternative to direct
composite resin.
To the authors’ knowledge, to date there
have been no reports published document-
ing the efficacy of adhesive aesthetic (resin
or ceramic inlays) for the treatment of CTS.
An in vitro analysis has shown that bonded
MOD ceramic (Cerec) inlays and laboratory
fabricated indirect resin bonded composite
inlays have the potential to increase the
fracture strength of human molar teeth
with wide cavities to values of similar
strength to that of sound, healthy teeth.42
The use of adhesive inlays may only
have a limited role in the management of
BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010
painful, cracked teeth. Their application
is time consuming, sometimes necessitat-
ing the use of a provisional inlay (which
may further accentuate the crack) and
require the removal of healthy hard tissue
undercuts, which is biologically invasive.
Furthermore, a five year study by Wassell
et al.,43 when comparing the failure rates,
wear rates and other aspects of clinical
performance of direct composite inlays
versus conventional composite resin res-
torations placed incrementally, revealed no
significant statistical difference between
the two forms of dental restorations.
INDIRECT RESTORATIONS
WITH CUSPAL COVERAGE
(ONLAYS AND FULL/PARTIAL
COVERAGE CROWNS)
While direct restorations placed intra-
coronally (without cuspal coverage) have a
role in the management of cracked painful
teeth, consensus opinion is that for wider
cavities in particular, there is a need for
cuspal coverage to further protect and
strengthen the residual tooth structure.23
The fabrication of direct restorations which
provide cuspal coverage is considerably
demanding of operator skill; the longev-
ity of direct plastic restorative materials
may also be a concern. The remainder of
this article will focus on indirect restora-
tions which provide cuspal coverage for
the treatment of CTS.
ONLAY RESTORATIONS
Conventional/adhesive metal onlays
The procedure for the preparation of a
tooth to receive a conventional cusp cov-
ered gold onlay has been meticulously
described and has been advocated for the
conservative management of damaged
occlusal surfaces of posterior teeth.44 While
historically they have been widely used for
the management of CTS, there appears to
be little clinical data to document their
effectiveness in this application.
The advent of newer generation dentine
bonding systems and the availability of
low viscosity chemically active cements
to bond tooth structure to either metals,
ceramic or composite resin, has paved the
way for restorations which may be used
to treat dental conditions in a very ‘mini-
mally invasive manner’.45 The adhesive
metal onlay ‘is an example of a minimally
© 2010 Macmillan Publishers Limited. All rights reserved
PRACTICE
invasive, indirect restoration that has been
used to treat cases of cracked tooth syn-
drome’.46,47 Examples are illustrated in
Figures 2 and 7.
Yap47 has presented a case report docu-
menting the application of a resin bonded
(adhesive) metal onlay for the management
of a patient presenting with CTS, involv-
ing the placement a cast cobalt chromium
alloy (Degussa, Germany). The prepara-
tion involved the reduction of the occlu-
sal surface by 1.0 mm over the functional
cusps and 0.7 mm over the non-functional
cusps; a shoulder design finish line was
applied circumferentially, 1.2 mm beneath
the prepared occlusal surface. The resto-
ration was reported to be in place for a
period of at least one year and the tooth
described to be asymptomatic. The use of
cobalt-chromium alloys on account of
their extreme rigidity permits an ultra-
conservative preparation.
The successful application of resin
bonded alumina abraded type III cast
gold alloy onlays (luted with Panavia
EX, Kuraray, Japan) to treat six cases of
CTS has also been described.46 In the lat-
ter study, all affected teeth were prepared
to accommodate metal to the thickness of
1.5-1.0 mm and restorative margins were
finished on enamel tissue, with a ‘small
chamfer’ placed 1-2 mm circumferen-
tially below the prepared occlusal surface.
Restorations were evaluated for a mean
service period of 48 months; no failures
were noted.
Figure 7 shows an incompletely frac-
tured symptomatic lower molar tooth
which has been restored by the application
of a gold adhesive onlay. The tooth has
been prepared to receive a cast type III gold
adhesive onlay; the occlusal surface has
been reduced by 1.0-1.5 mm and a cham-
fer margin applied circumferentially. This
cast gold overlay was conformative and
fitted to the existing vertical dimension.
The use of type III or type IV cast gold
alloys offer the merits of favourable wear
characteristics, ease of casting and finish-
ing, high corrosion resistance and ease of
burnishing.46 The formation of an oxide
layer on the fit surface of gold alloy adhe-
sive onlays by heat treatment at 650°C for
ten minutes or tin plating is thought to
increase adhesion with the chemically
active resin lutes.48
The adhesive onlay restoration quite clearly
509
PRACTICE

a d

e i

c f j

Fig. 7 (a) shows an incompletely fractured symptomatic lower molar tooth, (b) shows the presence of a canine guided occlusion despite
marked canine wear. (c) shows that the tooth has been prepared to receive a cast type III gold adhesive onlay with the occlusal surface
reduced by 1.0-1.5 mm and a chamfer margin applied circumferentially. (d) shows the bonded metal onlay restorations in situ. (e) shows
the upper molar tooth with a leaking posterior composite restoration and this tooth has also been prepared (f) to receive an adhesive onlay
restoration (g) with occlusal contacts shown in (h). Canine guidance is shown in (i) and this was modifed by the addition of resin composite to
ensure posterior disclusion upon lateral excursive movements, to provide protection to the recently placed restorations (j)

offers the advantage of being biologically
conservative of tooth tissue. Additionally,
it would also be reasonable to presume that
trauma to the pulpal tissues (which would
result from the process of tooth preparation)
would be less likely from the effects of less
invasive tooth preparations (than would be
the case from more aggressive tooth reduc-
tions). It has been well documented that the
prognosis of endodontically treated, frac-
tured teeth is relatively poor.35
The application of provisional adhesive
metal onlay restorations may, however,
be challenging, as may be the presence
of close proximal contact points, where it
may be necessary to extend the prepara-
tion beneath the contact area.47 The prepa-
ration and placement of metal adhesive
onlay restorations is also economically
costly and time consuming. The use of
adhesive metal onlays is also contra-indi-
cated among patients who display signs
of poor motivation and plaque control
respectively, where there are high aes-
thetic demands and where there is the
poor availability of tooth enamel at the
restorative margins.47

510 BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010

© 2010 Macmillan Publishers Limited. All rights reserved


The placement of metal adhesive onlays
in supra-occlusion may be a possible vari-
ation on the approach adopted by Chana et
al.,46 permitting a possible ‘ultra-conserv-
ative approach’ to treat CTS (utilising the
well documented Dahl concept), although
it is imperative that a positive diagnosis is
derived, and careful case selection under-
taken where the placement of a restoration
in supra-occlusion has been planned.
Figure 2 illustrates a case where a gold
adhesive onlay has been placed initially
in supra-occlusion for a tooth which has
been affected by an incomplete fracture.
The occlusal contacts have re-established
by the three month review. This is in agree-
ment with studies where crowns are inten-
tionally fitted high to avoid the need for
occlusal reduction.10
Ceramic onlays
(conventional/CAD-CAM)
The ability to etch and bond ceramic
materials to tooth enamel offers a possi-
ble aesthetic alternative to the use of metal
onlays. With the advent of more recent
leucite reinforced ceramics it has been
possible to fabricate all porcelain resto-
rations with a higher fracture resistance
and increased flexural and compressive
strengths respectively.2
Liebenberg 2 has published a report that
describes the protocol for the fabrication of
‘partial coverage porcelain onlays’ to treat
cases of cracked, painful teeth. The use of
such restorations is claimed to be very
effective in the treatment of CTS based
on anecdotal evidence of treating several
cases over a period of at least five years.2
Tooth preparation to receive the above
form of restoration essentially involves
the reduction of the weakened cup by 2.0
mm, followed by the placement of a cham-
fer/rounded shoulder of 2 mm in width
applied just beneath the prepared occlusal
surface(s).2 Emphasis has been placed on
the presence of enamel around the entire
peripheral margin and accurate prepara-
tion/impression making.
The use of ceramic onlays clearly involves
a greater level of tooth reduction than that
advocated for the placement of metal adhe-
sive onlays. As discussed above, this would
culminate in a preparation approach that
is less biologically conservative than that
for the preparation for an adhesive metal
onlay, yet less invasive than that for a full
BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010
coverage restoration. The application of an
indirect ceramic would also necessitate the
use of a provisional restoration. The need
for a provisional restoration in cases of
CTS has been postulated to increase the
risk of pulpal complications.25
However, with the advent of contem-
porary computer aided design/computer
aided manufacturing (CAD/CAM) systems,
such as Cerec (Sirona, USA), it is possible
to complete a restoration in one visit. The
advantages of a CAD/CAM porcelain par-
tial onlay restorations in cases of CTS, in
particular where acute thermal symptoms
are present according to Griffin1 include,
the absence of irritation from temporary
fabrication and cementation, reduced risk
of salivary and bacterial ingress from less
than ideal provisional restorations (which
may show signs of fracture, leakage or
displacement) and the absence of pulpal
stresses from a second visit which would
include restoration ‘try-in’, cementation,
further tooth desiccation and bacterial
exposure or possible hand-piece trauma.
A report has been published describing
two cases of CTS which were successfully
managed for a period of at least two years
post restoration by the application of CAD/
CAM generated partial coverage bonded
porcelain onlays.1 It is important to note
though that many practitioners may not
have ready access to CAD/CAM facilities;
furthermore the inability to use ‘layer-
ing techniques’ culminates in restorations
which may not carry optimal aesthetic
value. Technique sensitivity is a feature
commonly seen as a drawback to the use
of CAD/CAM manufacturing systems.
While dental porcelains can be used to
produce restorations of a high aesthetic
value, their property of low critical strain
in tension culminates in a relatively brit-
tle material which may display signs of
fracture with little or no plastic deforma-
tion. Processing flaws within the material
substructure may also lead to eventual
cracking. Occlusal adjustments of ceramic
restorations may initiate micro-fractures,
render the exposure of unglazed ceramic
(which may cause wear of the opposing
dentition) and repair of ceramic restora-
tions may be challenging.
Porcelain bonded partial coverage
onlays offer a more conservative alterna-
tive to full coverage restorations for the
management of CTS, with high aesthetic
© 2010 Macmillan Publishers Limited. All rights reserved
PRACTICE
value. However, their application is time
consuming (even with single visit restora-
tions) and costly.
Of particular concern to the present
authors is the high biological cost in terms
of occlusal surface reduction, which may
be concomitantly associated with a higher
risk of irreversible pulpal damage (than
may be the case with a metal adhesive
onlay preparation). The need to undertake
endodontic treatment may not only com-
promise the longevity of the affected tooth,
but also require re-making of the ceramic
onlay prosthesis. The latter is not only eco-
nomically costly, but will also involve the
further loss of healthy tooth tissue.
Indirect bonded resin
composite onlays
The bonded indirect composite onlay res-
toration offers an alternative treatment
option to the use of either direct composite
onlays or ceramic onlays in the treatment
of CTS. Indirect composite onlay restora-
tions have been shown to be effective for
the treatment of painful, cracked teeth.49
Depicted by Figure 8 is an example of a
symptomatic fractured, vital posterior tooth
which has been restored by the means of
an indirect resin composite onlay. Note the
need for a more aggressive level of tooth
reduction, when compared to the prepara-
tion for a tooth to receive a cast adhesive
gold onlay, as shown by Figure 7.
Deliperi et al.50 state that in compari-
son to direct composite resin onlays, the
indirect technique allows for restorations
which have more favourable anatomical
form, a more accurate occlusal prescription
and more predictable proximal contact
anatomy. It has been well documented that
the feature of polymerisation shrinkage is
a major drawback associated with the use
of direct composite restorations. The latter
complication is largely negated with the
use of indirect techniques (as much of this
takes place extra-orally); however, polym-
erisation shrinkage occurring at the level of
the resin lute may still feature. According
to Wendt,51 on account of a higher level
of polymerisation conversation attain-
able with indirect methods, such restora-
tions can be expected to display improved
mechanical and physical properties such
as strength and wear resistance.
When compared to bonded porcelain
onlays, both form of restoration require the
511
PRACTICE
same level of tooth reduction. However,
indirectly bonded resin composite onlay
restorations offer the merits of ease of
repair (with direct materials) and adjust-
ment respectively. They are also less abra-
sive towards opposing occlusal surfaces.
The potential to add direct composite may
be crucial in cases of CTS, where loss of
vitality may precede the cementation of
the definitive restoration, as the latter
can be readily repaired post-endodontic
therapy, without the need for a remake.
Furthermore, the indirect composite onlay
will continue to serve its purpose as a
splint, while root canal therapy is being
undertaken (particularly in cases where
treatment may be more than one visit).
Indirect composite onlays have been
shown to display a greater capacity
to absorb compressive loading forces,
thereby reducing the impact force on the
underlying tooth structure by 57%, when
compared to dental porcelain. The latter
property is thought to be accounted for
by the lower elastic modulus presented by
composite resin. A reduction in the load
transmitted to a fractured flexible tooth
is critical in preventing further progress
of the crack. Brunton et al.49 showed that
premolar teeth restored by the means of
composite onlays exhibited higher levels
of fracture resistance than equivalent teeth
restored with ceramic onlays.
It would appear that the weak link
associated with the use of indirect
resin composite restorations is the resin
based lute.50
Signore et al.52 have published the results
of a six year retrospective study describing
the clinical performance of bonded indi-
rect composite onlays for the treatment of
43 cracked, painful teeth. For cases where
cavity widths were less than half the dis-
tance from the central fossa to the cusp
tip, only the involved cusp was reduced;
for larger cavities, complete cuspal cover-
age was undertaken. All cavities were first
pre-restored with a directly bonded resin
composite, followed by a reduction by 1.5-
2.0 mm of the occlusal surface; all margins
were placed on sound enamel and usu-
ally placed supra-ginigivally. Onlays were
cemented using a 3-step total etch system
with the use of a dual cured low viscos-
ity composite cement (Variolink, Ivoclar,
Vivadent). A favourable survival rate of
93.02% was reported, suggesting that this
512
form of restoration may represent a suc-
cessful method of treating incompletely
fractured posterior teeth.
Indirect resin composite onlays appear
to have a role in the management of
CTS. They can provide an effective treat-
ment option and can overcome many of
the drawbacks associated with the use of
directly bonded composite onlays. While
their placement requires more tooth prepa-
ration, they are more conservative than
full coverage restorations and offer the
potential for effective repair. Cost and
time factors, together with the need for
temporisation, are obvious disadvantages.
Caution may need to be applied when con-
sidering their placement among patients
who display signs of tooth wear.40
Full coverage crowns
Based on their observation that cracks on
posterior teeth typically extend from the
occlusal incline to the cervical third of the
clinical crown, Gutherie et al.8 have advo-
cated the use of full coverage crowns to be
the most appropriate form of restoration to
manage cases of cracked tooth syndrome.
It has been argued that the resistance form
provided by a full coverage restoration
enables occlusal forces to be distributed
over the entire prepared tooth, thereby
minimising stresses which would otherwise
be relayed to the crack; while the reten-
tion form of the crown through the process
of frictional contact and by the action of
the cement lute helps to splint the tooth
fragments, thereby minimising their inde-
pendent movement when occlusal forces
are released.8
A modified preparation to the con-
ventional full coverage preparation (for
either a full veneer preparation or that
for a metallo-ceramic crown) has been
described, which is thought to reduce the
functional stresses applied to the fractured
segments.56 These modifications include: a
further reduction of the involved cusp with
the application of a subsequent bevel, the
avoidance of the placement of boxes and
grooves on or adjacent to the fractured
aspects of the tooth, placement of margins
more apically (which will improve bracing
of the crown by the surrounding tooth), the
use of adhesive core materials, the use of
thicker die spacers to permit the fabrica-
tion of a passively fitting restorations and
the use of low viscosity cements.
BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010
© 2010 Macmillan Publishers Limited. All rights reserved
a
b
Fig. 8 An example of a symptomatic
fractured, vital posterior tooth (a) with a
mesial fracture (see arrow) which has been
restored by the means of an indirect resin
composite onlay (b)
The efficacy of full coverage acrylic
provisional crowns in the management of
cases suffering from CTS was evaluated
by Gutherie et al.8 A failure rate of 11%
was reported; all of the failures required
endodontic therapy.
In a more extensive study, where 127
cases of posterior teeth with cracks with
concomitant symptoms of reversible
pulpitis were restored with full cover-
age definitive crowns, a staggering 21%
of cases were reported failed within the
first six months of evaluation; all cases
required subsequent root canal therapy.53
Cases with single marginal ridge fractures
(either mesial or distal) were reported to
be more likely to be in need of endodontic
treatment. The proportion of teeth (with
CTS) with the subsequent need of further
endodontic therapy 8,53 is significantly
higher following the application of full
coverage crowns than among those cases
which have been splinted by other restora-
tive means as described above.
Various studies have reported the loss
of vitality following the application of full
coverage single unit crowns to be in the
range of 15 to 19%.54,55 Loss of pulpal vital-
ity is an obvious problem following the
preparation of teeth to receive the latter
form of restoration; the problem appears
to be further compounded in cases of CTS,
where reversible pulpitis would generally
be an already pre-existing condition. It has

been reported by Tan et al.35 that endo-
dontically treated, cracked teeth have a
relatively poor long term outlook.
In cases where root canal treatment is
indicated following the application of a
definitive crown, this may necessitate the
remaking of the crown which further adds
to the cost of the procedure. The prepa-
ration of teeth to receive full coverage
crowns is also time consuming.
SUMMARY
A number of definitive different restora-
tions/restorative techniques have been
described for their respective use to treat
posterior teeth affected by CTS. However,
there is only very limited clinical evidence
available in the dental literature to sub-
stantiate the use of any of them.
The prognosis of a tooth affected by
CTS is determined by three principal fac-
tors, hence: the extent and location of the
fracture, the point in time when restora-
tive intervention is initiated and thirdly
by the type of restoration applied to splint
the fracture.
The prognosis of teeth involved by
CTS, where the presenting cavity is not
in excess of one half of the bucco-lini-
gual width when restored by the means of
directly bonded plastic restorations with-
out cuspal coverage, appears to be reason-
ably acceptable. The preparation of teeth
to receive such restorations is biologically
conservative, with the subsequent loss
of pulp vitality not being an associated
primary concern. The prognosis of root
filled cracked teeth in the longer term
appears poor.35
According to a leading authority, teeth
affected by CTS should be initially restored
by means of bonded direct restorations as a
means of immediate/intermediate therapy;
where an indirect restoration is indicated
from the outset, such a restoration should
only be placed after having managed the
immediate symptoms.25,26
Conventional full coverage crowns and
conventional onlays have been utilised as
a historical gold standard for the above
purpose.57 With the former, the copious
loss of tooth tissue and high risks of loss
of pulp vitality respectively are major
concerns, which may impart a consid-
erable negative effect on the prognostic
outcome of teeth affected when treated by
such an approach. The need for provisional
BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN 12 2010
restorations, cost and time factors are also
obvious drawbacks to the use of conven-
tional indirect restorations.
Adhesive metal and indirect resin com-
posite onlays may in time show some
level of considerable promise for improv-
ing the prognosis of teeth affected by CTS,
and form excellent definitive, long term
restorative options for the treatment of
teeth affected by this condition, in par-
ticular where affected teeth may have been
intruded by ultra-conservative restorations
placed in supra-occlusion. A more biologi-
cally conservative tooth preparation will
without doubt help to prolong the longev-
ity of the tooth but also help to prevent
irreversible pulpal damage.
Of the limited data available, it would
be fair to conclude that direct restora-
tions with cuspal coverage, in particular
bonded composite restorations appear to
be the most beneficial when considering
prognostic outcome of teeth restored for
the purposes of incomplete posterior tooth
fractures.25,26 Furthermore, their application
is cost effective, efficient and they also
permit an aesthetic outcome with limited
damage inflicted upon the dental pulp.26
However, the placement of direct composite
onlay restorations is very dependent upon
operator skill, and furthermore, some level
of tooth preparation is still required.
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