Treatment of cracked teeth: A comprehensive narrative review

Abstract

Objectives: The term "cracked tooth" is used to describe an incomplete fracture initiated from the crown and progressing towards a subgingival direction. Despite the high prevalence of cracked teeth and their frequent association with symptoms and pulpal or periapical pathoses, there is still no consensus in the literature with regard to their restorative and endodontic management. Therefore, the aim of this narrative review was to evaluate the most relevant research and provide an up-to-date comprehensive overview regarding the treatment of cracked teeth.

Materials and methods: An electronic literature search was carried out in MEDLINE (via Ovid), Embase (via Ovid), Scopus, and Web of Science as well as several "Grey literature" sources up to February 22nd 2022 using a combination of pre-specified 'free-text' terms (keywords) and "subject headings." The search process was supplemented by handsearching in relevant dental journals and reference lists. This narrative review focused on clinical follow-up studies (observational or interventional studies, case series/reports), laboratory studies and systematic reviews written in English language that reported data on treatment of permanent cracked teeth. The selection of relevant studies was carried out by two reviewers (AK and DG) working independently in two consecutive stages: title/abstract screening and full-text retrieval. Any discrepancies in the study selection were resolved by discussion between the reviewers.

Results: In total, 64 articles were selected for inclusion in this narrative review.

Conclusions: Cracked teeth with normal pulp or reversible pulpitis have exhibited high pulp and tooth survival rates by the provision of direct or indirect composite restorations. Besides, recent data favour monitoring, especially in the absence of symptoms or compromised tooth structure. When endodontic intervention is required, current evidence suggests that along with appropriate restorative management, outcomes of cracked teeth may be comparable to those of non-cracked root filled teeth.

Keywords: composite resins; cracked tooth syndrome; dental onlay; dental restoration failure.

Figure 1

Study selection process illustrated in a PRISMA flow diagram.

Figure 2

Direct composite restoration in an intact cracked 46 with reversible pulpitis (a) preoperative long‐cone periapical radiograph (b) crack line visible (arrows) after investigation with bur (c) composite restoration completed (d) periapical radiograph at 6 months follow‐up; the tooth has remained vital and asymptomatic.

Figure 3

Indirect composite onlay restoration in an intact cracked 14 with reversible pulpitis (a and b) preoperative long‐cone periapical radiograph and occlusal view (c) crack line revealed (arrows) after investigation with bur (d) onlay preparation (e) postoperative occlusal view with bonded indirect composite onlay (f) periapical radiograph at 6 months follow‐up; the tooth has remained vital and asymptomatic.

Figure 4

Treatment sequence of a cracked 46 with irreversible pulpitis (a) preoperative long‐cone periapical radiograph (b) access cavity for endodontic treatment revealing mesial and distal crack lines (arrows) and C‐shaped canal configuration (c) root canal obturation completed (d) periapical radiograph after completion of endodontic treatment (e) crown preparation (f) occlusal view after cementation of a metal ceramic crown.

Figure 5

Treatment sequence of a cracked 47 with irreversible pulpitis (a) preoperative long‐cone periapical radiograph (b) removal of previous amalgam restoration revealing multiple crack lines running towards mesiodistal (green arrows) and buccolingual direction (yellow arrows) (c) root canal obturation completed (d) periapical radiograph after completion of endodontic treatment (e) crown preparation (f) occlusal view after cementation of a metal ceramic crown.

Figure 6

Treatment sequence of a cracked 38 with irreversible pulpitis (a) preoperative cone beam computed tomography (CBCT) (b) occlusal view after removal of previous amalgam restoration (c) cuspal reduction and access cavity for endodontic treatment with visible cracks at mesial and lingual walls (arrows) (d) root canal obturation completed (e) preparation for indirect onlay restoration (f) indirect composite onlay bonded (g and h) postoperative occlusal view and CBCT image.