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 Incomplete fractures of posterior teeth are typically associated
occlusal splint for the symptomatic management and con- with the symptoms of sharp pain during biting and thermal
comitant protection of teeth diagnosed with cracked tooth hypersensitivity, usually to cold stimuli. The condition is
syndrome was described previously. This audit assesses its usually referred to as ‘cracked tooth syndrome’ (CTS).1 The
efficacy amongst 151 cases. In all, 131 were successful and aetiology of CTS is often multi-factorial.2
reported a reduction in symptoms before proceeding to The presenting symptoms of this condition can however
further treatment. 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 more accurately described as relative axial tooth movement,
have been frequently incorrectly diagnosed as CTS3 and are intrusion and extrusion, or occlusal adaption) as a possible
listed in Table 1. means of effectively, efficiently and economically treating CTS
It is generally accepted that a history of pain on biting (or in a minimally invasive manner.19 The DCS restoration
particularly on release), coupled with thermal hypersensitivity comprises a direct, ‘flat’ composite resin onlay applied
to cold and hyper-sensitivity to an applied cold stimulus, without any tooth preparation across the entire occlusal
together with a positive response to a ‘bite test’ is sufficient to surface, carried over across the external line angles to extend
arrive at a diagnosis of CTS.2 However, in the opinion of the at least one-third of the way down the axial (buccal, lingual or
authors, there is a lack of sensitivity with this approach. palatal) walls, respectively. Consequently, it is placed in a
The active restorative management of CTS is not simple; supra-occlusal position. The use of supra-coronal adhesive
however there is consensus for the need of immobilisation. A onlay restorations to treat cases of CTS in a minimally invasive
splint should aim to prevent the independent movement of manner is not a novel concept.15 There are, of course, certain
the fractured portions upon the application of a bolus to the limitations and indeed contra-indications to this approach.
affected tooth and prevent further progression of the fracture The Dahl concept has been historically, successfully
plane.4 applied for the management of localised anterior tooth wear,
In the acute scenario, symptomatic management has been as a means of creating intra-occlusal clearance without the
achieved by the placement of copper rings, stainless steel need for further tooth reduction.20–25 The phenomenon refers
orthodontic bands or provisional crowns to the affected to the tooth movements that take place when a localised
tooth.5,6 Copper rings and orthodontic bands are however appliance is placed in the supra-occlusal position, followed by
seldom at the ready disposal of most General Dental the concomitant re-establishment of full-arch contacts over a
Practitioners, are not well accepted by the periodontal tissues period of time.26
and furthermore may be associated with aesthetic concerns. A DCS can have several applications. In the first instance, it
The application of provisional, full coverage crowns is may serve as a diagnostic aid. Indeed, the authors initially
biologically invasive,7,8 costly, irreversible and time consum- advocated the placement of the DCS onlay restoration as a
ing. Furthermore, there is a risk of overtreatment if the ‘trial approach’ (without the use of an adhesive), so as to not
diagnosis is incorrect which a direct coronal onlay splint (DCS) only ascertain initial tolerance by the patient but to also help
avoids. confirm that the symptoms are from a specific tooth, that the
A variety of protocols have been described in the source of pain is pulpal and not periapical in origin. When
contemporary literature for the definitive management of directly bonded it may also provide relief from the symptoms
incomplete posterior tooth fractures, ranging from the of CTS by providing extra-coronal fixation and reduce fracture
application of directly bonded intra-coronal restorations,9–11 risk. Finally, a DCS restoration also has the potential to provide
directly bonded extra-coronal restorations10–12 and indirect the necessary intra-occlusal clearance required to accommo-
extra-coronal restorations with varying amounts of tooth date a more suitable definitive restoration without the further
coverage.13–15 The use of CAD-CAM-fabricated restorations need of hard tissue removal.19
has also been suggested.16 This technique has been in use for some time since initial
Evidence exists for the successful, medium-term use of publication, and therefore, the authors considered an audit
directly bonded resin restorations10,11 and indirect resin was due. The aim of this paper is to describe the outcome for
composite onlays13 to treat cases of CTS. Opdam et al.,10,11 the use of DCS restorations to treat cases of CTS by the means
have described a relatively good short term outlook for teeth of a multi-centred retrospective audit where a universal
affected by CTS to be managed by the placement of direct protocol had been applied.19
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 2. Materials and methods
longer term efficacy of this form of restoration appears less
predictable over one which offers cuspal coverage, perhaps A total of 151 patients diagnosed with CTS were included in
accounted for by an eventual breakdown of the adhesive this multi-centred retrospective audit. Patients had been
interface between the restoration and affected tooth from the treated at one of four separate General Dental Practices based
effects of cyclical loading.11 In order to provide cuspal in South-East England or at the King’s College London Dental
coverage without prescribing a change in the intercuspal Institute, London (KCLDI). Overall, five trained operator/
position, a more invasive protocol is usually necessitated. assessors were involved each known to the other either in
In 2010, Banerji et al. proposed the DCS based on the well- the capacity of colleague, Senior Clinical Teachers or post-
established concept of the ‘Dahl’ phenomenon17,18 (perhaps graduate Masters level students at the KCLDI. DCS restorations

Table 1 – A list of conditions/signs frequently misdiagnosed for CTS.

Acute periodontal disease Reversible pulpitis Dentinal hypersensitivity
Galvanic pain Post-operative sensitivity Fractured restorations
Hyper-occlusion Occlusal trauma Trigeminal neuralgia
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
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 halogen light curing unit for a period of 40 s.19 A ‘flat’ occlusal
therapy for the management of patients presenting with morphology was established in each case and Fig. 1 provides
symptoms of cracked tooth syndrome by minimal interven- an example of a trial splint as described above.
tion. Patients were requested to ‘bite down’ on to the splint and
A diagnosis of CTS had been derived where patients had verbally questioned about a possible reduction in their
initially reported a history of pain on chewing (or release) and symptom of pain on chewing/release. Where there was an
thermal hypersensitivity to cold stimuli, a positive response to alleviation of symptoms the occlusal splint was removed with
a ‘bite test’ and an exaggerated response to a cold stimulant a view to placing an adhesively bonded direct composite
when applied to the affected tooth. Bite tests were performed splint restoration. Where there was no alleviation in the
using a Tooth Slooth crack detector (Professional Results, symptoms described further diagnostic investigations were
USA).2 Sensitivity testing was carried out using a cotton wool undertaken. For cases where an improvement in the
pellet soaked with ethyl chloride (Endo-Cold Spray, Henry symptoms was reported but intolerance expressed, treat-
Schein). Each patient also provided a negative response or the ment was then provided according to established previously
complete alleviation of the symptom of pain on biting or documented protocols10–15 in a conformative manner (so
release following the application of a ‘trial’ (non-bonded) as to not involve an alteration of the position of maximum
extra-coronal splint to the suspected tooth. inter-cuspation).
For the provision of a non-bonded DCS suspected teeth For each patient a careful assessment of the eruptive
were dried with air and composite resin (Gradia Direct, GC potential was also carried out. Where the application of a
Corporation, Tokyo, Japan) was applied to the occlusal aspects restoration in a supra-occlusal position may have been either
of the teeth. Resin composite placement was carried along unpredictable (such as amongst cases with reduced eruptive
over the external line angles of the affected tooth, down onto potential) or where the placement of a supra-coronal restora-
the axial walls to approximately 3 mm short of the gingival tion be deemed potentially detrimental to the patients oral
margin. No local anaesthesia or alteration of the retentive (and health, DCS restorations were not advised. A reduced eruptive
adhesive) capacity of the affected tooth respectively was potential has been associated with patients who may present
required in any case. Resin composite was applied to attain an with anterior open bites, dental implants, fixed bridgework,
ultimate thickness of approximately 1.5 mm over the occlusal bony ankylosis, and severe class III malocclusions26 and
surface and 1.5–1.0 mm along the axial walls and cured using a 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- Occlusal contacts were checked using articulating paper.
tion(s) such as active periodontitis, temporomandibular joint Where the application of the DCS rendered the affected tooth
pain dysfunction syndrome or for those patients who may to be in contact during mandibular lateral excursive and
have received prior orthodontic therapy, where the placement protrusive movements resin composite was added to the
of restorations in supra-occlusion may indeed lead to an guiding tooth to avoid non-axial loading of the splint,
exacerbation of the underlying condition(s) or destabilisation frequently referred to in the literature as a ‘canine riser’ or
of the occlusal scheme established then therapy by the means ‘Stuart lift, as described by Murray et al.27 An example is
of a supra-coronal restoration was not considered suitable. shown by Fig. 3.
Long cone periapical radiographs were also taken of Patients were recalled after a period of 2 and 4 weeks;
suspected teeth to exclude the presence of unfavourable root however all recipients of DCS restorations were informed to
morphology, unfavourable crown to root ratios, the presence contact their respective dental operators in the event of any
of peri-radicular pathology or any signs of internal or external concerns, such as an exacerbation of their symptoms or
root resorption. A six-point periodontal assessment of each intolerance. At the review appointments all patients were
affected tooth was carried out using a Williams Probe. verbally questioned about a possible alleviation of their
Prior to the application of the DCS the temporomandibular symptoms of pain on chewing (or release) and hypersensitivi-
joints and associated musculature were checked. Occlusal ty to cold. Patients were also asked about their tolerance to the
contacts in the intercuspal position and during movements above approach. Restorations were assessed to confirm
were identified using articulating paper and noted; an exercise structural integrity and teeth assessed for signs of tooth
carried out as part of a routine examination amongst each of mobility.
the involved assessors. Occlusal contacts in the intercuspal Following a period of a further 3 months (12 weeks) post-
position were further identified using 8 mm thickness articu- operative, all cases received a third review (where there had
lating foil (Shimstock, Hanel), and documented. A record was been no reason to halt treatment at a first recall stage). Bite
also made of the restorative status of the tooth as well as an tests and cold tests were repeated with the aid of a Tooth
assessment of the opposing dentition. Slooth device and Endo Cold-Spray. The structural integrity of
All patients that were provided DCS restorations were the DCS was also re-assessed. Occlusal contacts in the
advised of the risks of intolerance, exacerbation of symptoms, intercuspal position and on excursive and protrusive man-
increased mobility of the affected and antagonistic tooth, dibular movements were checked and documented. Shim-
fracture(s) of the restoration, antagonistic tooth and affected stock Foil of 8 mm thickness was used to verify the re-
tooth, difficulties with speech, food stagnation, mastication establishment of occlusal contacts in the inter-cuspal
and the risk of developing signs and symptoms of TMJ pain position.
dysfunction syndrome.
Having obtained patient approval, affected teeth were
cleansed with slurry of pumice applied with a rubber cup. 3. Results
Isolation was achieved by the use of cotton wool rolls and
suction. Placement of the bonded DCS restoration was carried Of the 151 patient’s included in this audit 37.7% were male
out as described by Banerji et al.,19 37% Orthophosphoric acid patients and 62.3% female. The mean age of the sample was
gel was applied to the affected tooth over the occlusal and 50.5 years, with a range of 30–80 years.
axial walls for 30 s. Optibond Solo Plus (Kerr, Italy) a two-step A further 11 patients had been diagnosed positively with
combined primer/bonding agent dentine adhesive was ap- CTS with the aid of the DCS restoration prior to adhesion but
plied according to the manufacturer’s recommendations over had declined the placement of a supra-occlusal restoration.
the etched surfaces. Resin composite (Gradia Direct, GC, Shade Ten of the latter were male and were subsequently excluded
PA2) was dispensed from a compule in increments of 1.0 mm, from the audit. Seven of these patients were managed by the
to attain a final material thickness of 1.0–1.5 mm. Each placement of a directly bonded resin onlay restoration, one by
increment was contoured to approximately follow the a Type III adhesive gold onlay restoration and the remaining
anatomical outline of the affected tooth, and each increment three immobilised by the means of full coverage crown
cured for a period of 40 s. Resin composite was therefore restorations.
placed not only over the occlusal surface but also along one- As depicted in Table 2 the most frequently affected teeth
third of the axial walls. Restorations were then coated with a by the condition were mandibular first molar teeth, account-
layer of glycerine and post cured for a period of 40 s. ing for 29% of the sample. Maxillary first molar teeth, followed
Excess resin composite was generally removed with the aid a by mandibular second molars, maxillary second molars,
fine needle-shaped composite finishing diamond bur in a high- maxillary first molars, maxillary second premolars, mandib-
speed hand-piece. Restorations were finished using a sequence ular second premolars, mandibular first premolars and
of dental polishing stones; a green dental stone followed by a maxillary third molars were affected in descending order.
white stone (Durastone, Shofu Inc., Kyoto, Japan). Inter-proximal There were no mandibular third molars encountered in the
excess was removed with the aid of hand-held inter- sample. Overall, 45% were maxillary teeth and 55% were
proximal separating strips (West One Dental) to make sure mandibular.
inter-proximal contact areas were amenable to dental flossing. When considering the restorative status of the 151 teeth,
Fig. 2 provides an example of a lower second molar, which 113 (74.8%) had restorations present. Additionally, canine riser
has been affected by an incomplete fracture. The tooth has restorations had been provided for 19 of the cases (12.6%) of
been managed by the application of a DCS restoration. the sample.

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 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% (or release) and thermal sensitivity, or indeed, where there
was determined for the complete resolution of the signs and has been an exacerbation of the pre-operative symptoms. Of
symptoms of CTS within 3 months of restorative intervention the latter 16 patients, 11 had developed signs and symptoms
with a DCS restoration. Only one patient had persistent of irreversible pulpitis, while five patients had returned for
symptoms of mild pain on biting at this point of recall remedial attention with progression to a complete fracture
(Table 4); however, interestingly there had been a failure for involving the periodontal tissues. The majority of the patients
occlusal contacts to be completely re-established within the who presented with pulpal or periodontal complications
time frame of 3 months of recall for this given case. The latter following the application of the DCS restoration had returned
patient had however reported an overall improvement, and were identified within the first 2 weeks of placement.
whereby the detriment caused by post-restorative symptoms When considering the placement of a posterior restoration
was considerably less than that perceived prior to the in supra-occlusion, (excluding patients where further treat-
application of the supra-coronal splint and was willing to ment had been terminated due to further pulpal or periodontal
persist with the restoration in situ. This case was classified as involvement, and those which failed to fulfil the exclusion and
being ‘successful’ as there was no pain on biting as elicited inclusion criteria respectively), only 4/135 patients reported an
with a bite test. intolerance to the restoration with an overall acceptability of
Of the initial 151 cases included (which satisfied the 97% (131/135) as seen in Table 3. As noted above, each of the
selection criteria), 20 patients were excluded between the latter cases also returned within the first 14 days of placement.
point of placement of the restorations and the 3-month recall Fracture immobilisation was subsequently performed in a
period. For each of the latter, treatment was terminated. manner where there was confirmation of the pre-existing
Overall 16/20 cases were aborted as a consequence of there occlusal scheme; three cases received full coverage crowns
being a lack of alleviation of the symptoms of pain on biting 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 7

Table 5 – Table to show the resolution of occlusal approximately of 2:1 (female to male) was reported in a
contacts at the 3-month recall. previous epidemiological investigation.1 This disparity not a
consistent finding28,29 but may be accounted for by a lesser
Cases* Occlusal contacts
tendency for male patients to report symptoms.1 Patients in
Re-established Not re-established this audit were included in a purely random manner.
at 3-month recall The mean age of the patients affected by CTS in this sample
131 (100%) 128 (97.7%) 3 (2.3%) was 51 years, with a range of 30–80 years. As patients are
*
Cases lost due to pulpal and periodontal involvement at 3-month retaining their teeth into older age it is not unreasonable to
recall period have been excluded. 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-
effects were however reported following the initial prescrip- ed by incomplete fractures contained restorations which may
tion of a less biologically invasive approach. have weakened the tooth.32
Pre-restorative occlusal contacts were re-ascertained in the Mandibular first molars were most frequently noted to be
remainder of the sample within a period of 3 months amongst affected by CTS which has been reported by others.33 It has
128 of the 131 (97.7%) following the placement of the DCS been suggested that the ‘wedging effect’ imparted by the
restoration (Table 5). prominent mesio-palatal cusp of the maxillary first molar onto
As shown in Table 4, of the 131 cases which reported a mandibular first molar teeth, increases the predilection of the
complete resolution of the symptoms of CTS following a 3- latter towards fracture.30
month recall, 70.6% did report difficulty with chewing where a An overall success rate of 86.7% was reported for the DCS
supra-corornal restoration had been placed within the first 2 resin onlay restoration for the complete resolution for the
weeks of placement. However, at the 4-week reassessment, symptoms of CTS. Each of the operators were however very
only one patient (of the previous 94) had returned with this familiar with the protocol published in 2010.19 The high level
opinion, which had resolved at the 3-month recall. While of reported success is comparable to that reported for other
initial concern with the lack of masticatory efficiency was the means of attaining intra- or extra-coronal fixation.10–15 The
most predominant short-term complaint expressed, only one inclusion of a control group would have added further
patient had reported difficulty with speech (whereby they had significance to the data recorded but is not feasible in an audit.
developed a lisping tendency) and one had presented with The DCS restorations included in this audit were only
signs and symptoms of temporomandibular joint pain followed up for a period of 3 months. The short time frame
dysfunction syndrome, both cases had reported an improve- was reflective of the nature of the restoration, being of a
ment in these symptoms at the 4-week recall (Table 4). ‘provisional’ variety. However the successful resolution of
Thirteen patients (9.7%) had returned within the first 2 acute symptoms of CTS coupled with occlusal re-establish-
weeks of DCS placement requiring remedial attention where ment was attained for more than 97% of the sample within this
there has been either a complete fracture, de-bonding or time frame. The authors of the present investigation had
minor chipping of the plastic based direct resin based replaced the DCS restoration with a more aesthetic or durable
restorations (Table 4). Restorations were replaced or repaired definitive extra-coronal restoration by the removal of the
accordingly and each of these cases was deemed successful at bonded restoration, as discussed below.
the 3-month recall interval where the restorations were Canine riser restorations were provided in just over a tenth
shown to be functionally satisfactory with a complete of the sample. There was no correlation between failure rates
resolution of their symptoms of CTS. Only 2.2% of the initial and the provision of such restorations. Generally, canine risers
sample (3/135) were shown to display signs (or symptoms) of were removed following the placement of the definitive
increased initial tooth mobility (when compared to the pre- restoration but in some cases they were retained where signs
restorative status) following the placement of the DCS; of tooth wear may have been noted on the guiding tooth.
however each of the latter cases demonstrated no adverse Krell and Rivera14 have described a relatively large
signs or symptoms at the 3-month recall following the re- proportion of cases of CTS, managed by the fabrication of
establishment of pre-restorative occlusal contacts. full coverage crown restorations, to require root canal therapy
Pearson Chi-squared tests were carried out on the data within the first 6 months of evaluation. They considered that
relating to the gender of the sample, symptoms of intolerance, the pulpal tissues are likely to have acquired some level of
difficulty with chewing and the complete resolution of ‘distress’ or inflammation due to the presence of a pre-existing
occlusal contacts following the placement of a DCS restoration crack, culminating in the seepage of noxious stimuli or
respectively. Using a 2 way table upon which measures of bacteria towards the dental pulp upon biting. It has also been
association were computed as a constant, no measures of documented that the prognosis of cracked, root-filled teeth
association were determined following the cross-tabulation of managed by full coverage crowns remains bleak.34
each of the aforementioned variables. 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-
4. Discussion more, definitive restorations (Figs. 4 and 5) can be applied
without the need for further subtractive tooth preparation
In this present audit just under twice as many female (other than a distinguishable preparation margin) simply
patients were diagnosed as suffering from CTS. A ratio of by the removal of the DCS restoration, as the 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
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 effects had been noted as a consequence of initially prescrib-
process relative axial movement, thereby alleviating the need ing a supra-coronal restoration.
for further biological injury frequently cited to occur with the Overall, 20 failures were observed amongst the initial
prescription of full-coverage crown restorations.7,8 sample. Failures were due to either the subsequent develop-
For the 128 cases where there was a successful resolution of ment of pulpal necrosis (55%), complete fractures (25%) or
the symptoms of CTS and re-establishment of the pre- intolerance (20%). It is very likely (regardless of the chosen
intervention occlusal contacts full coverage crowns were means of attaining appropriate immobilisation) that a small
provided for 18 of these patients (14.0%), Type III adhesive gold proportion of teeth within the sample would have inevitably
onlay restorations (Fig. 5) for 10 patients (7.8%), indirect resin progressed to have pulpal or periodontal complications. It is
composite onlays for 2 cases (1.6%), conventional (mechani- impossible to have ascertained the exact extent of the crack at
cally retained) cast gold onlays were provided for 3 cases (2.3%) the point of diagnosis. The DCS restoration may be readily
and the remaining 95 patients prescribed direct posterior resin removed should symptoms persist, or indeed should subse-
onlay restorations (Fig. 4) representing 74.3% of the successful quent endodontic therapy be required.
cases. Restorations were placed between 3 and 6 months of The DCS restoration also offers relative ease of applica-
symptomatic resolution and occlusal contact re-establish- tion. Many general dental practitioners may not have ready
ment being attained. The authors intend to follow up and access to copper rings or orthodontic bands,5 or indeed the
document the outcome of these cases. skills and knowledge to successfully place the latter. The
Brady and Maxwell35 have shown that in almost one-fifth of preparation of a tooth to receive a provisional crown for the
all referrals made to specialist endodontists (where ambiguity acute management of symptomatic, incompletely fractured
exists over the precise diagnosis of the presenting symptoms) posterior teeth is not only time consuming but highly
an eventual diagnosis of incomplete tooth fracture is made. invasive and indeed irreversible.6 Patients often have to be
The DCS restoration has the potential to not only assist with recalled as it is seldom possible to undertake a crown
the establishment of a diagnosis of CTS but is readily preparation and provide a provisional crown in the acute
reversible. Indeed, among the small proportion of cases that scenario. Any undue delays in providing appropriate
reported a poor tolerance or acceptance of a supra-coronal immobilisation of a fracture may result in continued
restoration, no untoward short- to medium-term adverse 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
Fig. 5 – To show an example of a Type III gold adhesive position. According to the results of this audit a success rate of
onlay, used to substitute a DCS restoration following 97.7% was determined. The patient’s age and sex had little
successful symptomatic management. Minimal influence on success or failures. A successful outcome in this
preparation has been required. audit was determined by the ability of the supra-coronal resin

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 9

onlay restoration to provide the effective resolution of the At the fortnightly recall one patient reported a phonetic
symptoms of CTS and to provide the desired intra-occlusal disturbance and another patient developed signs and symp-
clearance. This enabled the provision of a definitive restora- toms of TMJ dysfunction. However both found these to be
tion with cuspal coverage in a minimally invasive manner and transient and resolved within the first month. Analogous
the subsequent re-establishment of the occlusal contacts. results have been reported with respect to these complaints by
The concept of placing restorations in supra-occlusion to workers when placing anterior supra-coronal restorations.20,23
gain intra-occlusal clearance has been well documented in the A very small proportion of patients were noted to develop
dental literature for the management of localised anterior signs of tooth mobility (2.2%) following the application of a
tooth wear.20–25 Space is estimated to have been created by a supra-coronal restoration which returned to normal following
combination of extrusive (60%) and intrusive movements the re-establishment of occlusal contacts. The incidence of
(40%) of the teeth.26 An element of mandibular repositioning of external root resorption is a possible detrimental effect of
the condyles has also been suggested to take place.20,21 orthodontic tooth movement. There is no evidence to suggest
The success rate determined by the outcome of this audit is this would occur with the use of the supra-occlusal restora-
comparable with the values reported by other groups; where tions possibly due to the existence of protective inhibitory
supra-coronal restorations have been prescribed for the feedback from the periodontal ligament.26
conservative management of localised anterior tooth Overall, 9.7% of the sample reported with restoration
wear.20–25 Each of the latter have reported success rates in failures related to either the occurrence of a complete fracture,
the range of 94–100%. Poor compliance with removable de-bonding or minor chipping. All failures were readily
prosthesis and the possible lack of stable occlusal contacts addressed and each case subsequently progressed to success-
in either centric relation or the inter-cuspal position have been ful management of CTS. Failures in the anterior region, where
cited as common reasons for failure.20,23 The high success rate restorations are placed in supra-occlusion for the manage-
in the present audit may be attributable to the careful pre- ment of localised anterior tooth wear are less commonly
operative assessment of cases. Patients who displayed a observed to occur.21
reduced eruptive potential, or where the placement of a supra- Failures in the posterior dentition of resin restorations
coronal restoration may have been detrimental or poorly applied in supra-occlusion may however be reflective of the
tolerated were not recommended such restorations. inherent shortcomings of resin composite where it is applied
Interestingly, occlusal contacts were re-established within to areas of high occlusal loading. Indeed, Bartlett and
a relatively short period of time (3 months) following posterior Sundaram37 have reported the short-term prognosis for the
restoration placement. Historically, where restorations have use of micro-filled resin onlays for the management of
been applied in the supra-coronal position for the manage- severely worn teeth to be poor. The selection of an appropriate
ment of anterior wear, mean times of between 4.6 months,20 composite resin, the manner in which it is applied, and the use
5.9 months,23 6.2 months,22 9 months,24 and 7 months21 have of an appropriate adhesive system may all be factors that
been reported as being taken for contacts to re-establish. The require further consideration when fabricating a DCS restora-
comparatively short period of time within which occlusal tion. In contrast, Hamburger et al.,38 have elucidated a very
contacts were re-established may also be a reflection of the acceptable failure rate of 6.9% for 332 over a mean observation
relatively higher occlusal loads which may be applied in the period of 4 years for posterior direct resin composite
posterior dentition (which may be 2–4 times greater for restorations for the treatment of severe tooth wear at an
premolars and molar teeth respectively) when compared to increased occlusal dimension using a hybrid composite resin
anterior teeth,36 which may indeed hasten the process of (versus a microfilled variety). A similar prognostic outcome
dento-alveolar compensation. was described by Attin et al.,39 for analogous restorations
There were only three cases where occlusal contacts were applied for the treatment of erosive worn dentitions when
not re-established within 3 months. However, in each of these observed for 5.5 years; however, marginal deterioration and
cases ‘partial closure’ was observed and continued compen- discoloration and some loss of surface texture was reported.
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 5. Conclusion
their posterior occlusal contacts at a 10-year follow-up;
however, all of these cases were asymptomatic. This audit has provided evidence to support the use of a direct,
A surprisingly high tolerance rate (acceptance) of a resin composite onlay coronal splint (applied in supra-
posterior supra-coronal restoration of 97.03% was recorded. occlusion) as a minimally invasive alternative to conventional
The latter may be again accounted for by the means in which protocols for the diagnosis and management of symptomatic,
consent was obtained and the application of clinical criteria incomplete posterior tooth fractures. This form of restoration
before a DCS was used. Similarly high levels of patient may be readily applied (and removed), offering contingency
acceptance have been described by Hemmings et al.20 Diffi- planning with little financial cost being incurred. However,
culty with chewing was a consistent feature noted in this careful case selection is paramount. Evidence has also been
audit, reported by approximately 70% of the patients. provided for the predictable use of posterior restorations
However, this complaint resolved in 98.9% of the patients placed in supra-occlusion, provided a meticulous pre-opera-
within the first 14 days post restoration. It is important that tive assessment of the eruptive potential and dental health is
patients are made aware of this potential effect when carried out. Patients are likely to suffer with transitory
obtaining consent. difficulty with chewing and should be consented accordingly.

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

10 journal of dentistry xxx (2014) xxx–xxx

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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