Received: 17 April 2023

| Revised: 6 July 2023

| Accepted: 8 July 2023

DOI: 10.1002/ccr3.7714

CASE REPORT

Management and prognosis of a vital cracked tooth by

occlusal veneer for 14 months: A case report

Mengke Wang1 | Yingying Hong2 | Xiaomei Hou1 | Yinfei Pu3

1
Second Clinical Division, Peking University School and Hospital of Stomatology and National Center for Stomatology and National Clinical
Research Center for Oral Diseases and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, People's
Republic of China
2
First Clinical Division, Peking University School and Hospital of Stomatology and National Center for Stomatology and National Clinical Research
Center for Oral Diseases and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, People's Republic of
China
3
Department of Oral Emergency, Peking University School and Hospital of Stomatology and National Center for Stomatology and National Clinical
Research Center for Oral Diseases and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, People's
Republic of China

Correspondence
Xiaomei Hou, Second Clinical Division,
Peking University School and Hospital
of Stomatology and National Center
for Stomatology and National Clinical
Research Center for Oral Diseases
and National Engineering Research
Center of Oral Biomaterials and Digital
Medical Devices, Beijing, 100081,
PR China.
Email: houxiaomei1108@163.com
Yinfei Pu, Department of Oral
Emergency, Peking University School
and Hospital of Stomatology and
National Center for Stomatology and
National Clinical Research Center for
Oral Diseases and National Engineering
Research Center of Oral Biomaterials
and Digital Medical Devices, NO. 22,
Zhongguancun South Street, Haidian
District, Beijing 100081 China.
Email: puyinfei@yeah.net
Key Clinical Message
An occlusal veneer is an ultrathin restoration method and a minimally invasive
approach that can preserve more dental tissue and provide better aesthetic out-
comes, thus increasing patient satisfaction.
Abstract
An occlusal veneer is an ultrathin restoration method and a minimally invasive ap-
proach that can preserve more dental tissue and provide better aesthetic outcomes,
thus increasing patient satisfaction; however, no previous studies reported on treat-
ing cracked teeth using occlusal veneer. Accordingly, we described the diagnosis
and treatment process of a cracked tooth using occlusal veneer in a single case. A
29-­year-­old male presented at our dental clinic complaining of biting pain in the
mandibular molar on the right-­hand side. A routine oral examination with radiogra-
phy was performed to evaluate the oral condition and treatment planning. The #16
tooth had a crack line surrounding the whole distal–­lingual cusp from the occlusal
surface. After discussing various therapeutic options with the patient, an occlusal
veneer was performed. One week after treatment with occlusal veneer, the patient
had no complaints. A 14-­month follow-­up showed promising clinical and radio-
graphic outcomes. Occlusal veneer is an alternative treatment option for a cracked
tooth, as it can preserve more dental tissue and potentially save pulp vitality.

KEYWORDS
cracked tooth, minimally invasive dentistry, occlusal veneer, vital cracked tooth

Mengke Wang and Yingying Hong contributed equally to this work.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2023 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.

Clin Case Rep. 2023;11:e7714.  wileyonlinelibrary.com/journal/ccr3 | 1 of 6

https://doi.org/10.1002/ccr3.7714
2 of 6 |    WANG et al.
1 | I N T RO DU CT ION
Cracked tooth syndrome, also known as a fractured
tooth, is a common, well-­documented condition in chil-
dren and older people. It is often small and harmless
and occurs due to morphologic, physical, and iatrogenic
factors, such as steep cusp to fossa inclination, bruxism,
clenching, extensive attrition, or abrasion.1 A cracked
tooth is defined as a thin surface disruption of enamel
and dentin of unknown depth or extension or an incom-
plete fracture initiated from the crown extending subgin-
givally, usually directed mesiodistally.2 Various clinical
symptoms have been reported depending on the direc-
tion of the crack line and the extension of the crack.3
Common symptoms include pain on release after biting,
pain on biting, and thermal sensitivity.4 Nevertheless,
the pain from a cracked tooth can be difficult to distin-
guish from other conditions, such as atypical orofacial or
ear pain, migraine, temporomandibular joint disorders,
and sinusitis. Thus, establishing a diagnosis may be clin-
ically challenging.5 However, even with the assistance of
various diagnostic methods, the diagnosis is also diffi-
cult because diverse factors cause it, and the symptoms
vary depending on the severity of the crack. Therefore,
early detection and appropriate treatment are important
for retaining the tooth.
Managing cracked teeth can also be challenging, as it
involves mechanical and biological considerations. The
treatment often consists of root canal therapy (RCT) ac-
cording to the pulpal and periradicular diagnosis and full
cuspal coverage with bonded restorative materials. Full
cuspal coverage restorations (i.e., full crown) have been
used for many years to restore esthetics, occlusion, and
function, showing satisfactory clinical and mechanical
performance.6 Mechanically, cuspal coverage can splint
the incompletely fractured segments, reducing cusp flex-
ure.7 Still, for the vital cracked teeth treated with a full
crown, loss of pulp vitality is the most frequently reported
biological complication, with an incidence rate of 2.1% at
5 years, which can reach as high as 15%.6
An occlusal veneer is an ultrathin restoration that re-
lies on bonding for retention and can completely cover
cusps. It is used to treat occlusal developmental defects,
chemical or mechanical abrasion, and reconstruct some
occlusal surface morphology.8 Compared to a full crown,
an occlusal veneer is less invasive, can preserve den-
tal tissue, and provides better aesthetic outcomes and
higher patient satisfaction.9–­11 Nevertheless, no previous
studies reported on treating cracked teeth using occlusal
veneer.
In this study, we described the diagnosis and treatment
process in a single case of a cracked tooth using occlusal
veneer.
2 | C ASE REPORT
2.1 | Medical history and clinical
findings
A 29-­year-­old male visited our department (2nd Dental
Center, Peking University School and Hospital of
Stomatology) and was referred for an endodontic consulta-
tion. The patient's primary complaint was pain associated
with the mandibular molar on the right-­hand side when bit-
ing hard food. The patient had no significant medical history
or systemic disease. In addition, he was avoiding chewing
on the right side because of occasional sensitivity to cold
(symptoms lasted for 4 months and were getting worse).
The patient did not recall chewing recently on a hard ob-
ject, nor did he have a parafunctional habit of bruxism and
clenching. He also had no history of trauma or injury.
Clinical and radiological examination (Figure 1) showed
healthy teeth in the right mandibular region with no previ-
ous restorations or signs of periodontal disease. The final
offending tooth was #16 with a steep cusp, which also had a
distinct crack line on the distal–­lingual cusp, involving the
entire cusp from the occlusal surface (Figure 2).
2.2 | Diagnosis
After confirming the offending tooth, detailed clinical and
radiographic examinations were performed to obtain ac-
curate pulpal and periapical diagnoses and periodontal
and restorative assessment. As shown in Figure 2, the
#16 tooth had a single crack line surrounding the distal–­
lingual cusp and no occlusal interference. Further in-
traoral examination revealed that the #16 tooth (Figure 1)
was a healthy periodontium (with probing depth ≤3 mm),
caries-­free tooth, without composite resin fillings, and
with age-­appropriate signs of attrition.
A periapical radiograph in the distant paralleling
technique of tooth #16 was taken, revealing a uniform
periodontal ligament space associated with this tooth
(Figure 1D). Pulp testing with refrigerant spray caused an
immediate and short reaction (lasting 2, 3 s), suggesting
normal pulp vitality. Moreover, the #16 cracked tooth ex-
hibited no pain to percussion either from the vertical or
the lateral direction. The offending tooth showed a biting
sensitivity when examined with a small cotton ball. Tooth
Slooth testing suggested that the distal–­lingual cusp was
symptomatic. Also, the cracked tooth had normal physi-
cal mobility and no palpation pain, spontaneous pain, ab-
scess/swelling, or sinus tract.
After obtaining the patient's consent, the treatment
plan was established. The advantages and risks of vari-
ous therapeutic options, including direct restoration, the
WANG et al.
F I G U R E 1 (A) Clinical presentation of the mandibular right molar region. All teeth were healthy and caries-­free, with age-­appropriate
signs of attrition and without previous restorations. (B) Clinical presentation of the maxillary right molar region. The #16 tooth had a steep
cusp with a crack line on the distal–­lingual cusp. (C, D) The periapical radiograph of mandibular (C) and maxillary (D) right molar region.
The X-­ray films revealed normal width of the periodontal ligament and without periapical lesion.
F I G U R E 2 (A) The amplification clinical images of the #16
tooth displayed a distinct crack line on the distal–­lingual cusp and
surrounded the whole cusp from the occlusal surface as the black
line displayed. (B) The clinical presentation of the lateral occlusal
contacts in the right molar region. No occlusal interference and
deep overbite and overjet were found.
full crown, and the full crown with preventive RCT, were
discussed with the patient. We recommended the min-
imally invasive therapeutic option (i.e., occlusal veneer)
that included cuspal coverage restoration with less tooth
preparation and did not require preventive RCT, which
the patient eventually accepted.
2.3 | Therapeutic strategy
The #16 cracked tooth was prepared as a standardized
and cuspal-­covered occlusal veneer, with 0.5-­to 1-­mm
width rectangular or angular (slightly <90°) shoulder
and a round and sharp inner line angle to fully cover the
whole occlusal surface. In order to obtain effective pain
control, local infiltration anesthesia with 4% articaine
   | 3 of 6
hydrochloride (containing epinephrine at a concentra-
tion of 1:100,000) was adopted before the operation. The
functional cusps and the cusp with the crack line were
reduced (dentin removed) by 1.0–­1.5 mm parallel to the
cusp incline with a coarse diamond rotary cutting instru-
ment (Figure 3B).
As shown in Figure 3B, the orientation of the cracks
was more apparent after the intervention was com-
pleted. The depth on the occlusal surface was 1.0–­
1.5 mm in thickness along the axial walls, which was
needed to finish in an infinity bevel and supragingival.
After preparation, the whole tooth surface was cov-
ered by the Hybrid coat (Sun Medical Co., Ltd.) to re-
lieve the dentin sensitivity and avoid pulp stimulation.
Moreover, we maintained partial cracks and ensured re-
storative space and the inexistence of caries, which was
supported by the reported literature.12 In the study, the
authors argued that keeping partial cracks could guar-
antee enough space for restorations and prevent further
crack progression.12
After 2 weeks with a temporary restoration, no signs
or symptoms of inflammation (by subjective symptom
and cold test) were seen, so the definitive occlusal veneer
was placed following the instructions. Next, the definitive
occlusal veneer was tried-­in repeatedly to fit the occlusal
morphology, after which the final occlusal state at centric
occlusal contact (Figure 3C) and lateral occlusal move-
ment (Figure 3D) were recorded.
2.4 | Data collection during follow-­up
Clinical follow-­up of the cracked tooth was reexamined
at 1 week, 1, 2, 3, 6, and 12 months after surgery, and then
4 of 6 |    WANG et al.

F I G U R E 3 (A, B) The clinical presentation of the maxillary right first molar before treatment (A) and after intervention (B). The
cracked line was distinct as the black arrow displayed. (C, D) The centric occlusal contact imprinting (C) and lateral occlusal contacts
imprinting (D) after the occlusal veneer were try-­in repeatedly and bonded with the teeth. (E, F) The centric occlusal contact imprinting (E)
and lateral occlusal contacts imprinting (F) after the occlusal veneer were used for 6 months.

annually after that. The presence or absence of symptoms,

pulpal responses to the cold test, responses to palpation
and percussion tests, and periodontal probing depths
measurements were reassessed at each follow-­up. In ad-
dition, tooth #16 and both adjacent teeth were clinically
tested for the painful reaction after loading the individual
cusp using the Tooth Slooth. The success of the occlusal
veneer was defined as the absence of signs or symptoms
without progressive radiographic pathosis.
The biting pain was relieved after 1 week. The pulp
testing with refrigerant spray was normal, and the tooth
had a healthy periodontium with a probing depth ≤3 mm.
Moreover, after applying the occlusal veneer, the tooth
was asymptomatic with a percussion test and a biting test
with a small cotton ball. F I G U R E 4 The clinical presentation of the maxillary right first
After 2 weeks, no signs or symptoms of inflammation molar after the occlusal veneer at 14 months follow-­up. The centric
occlusal contact imprinting (A), and the centric and lateral occlusal
were observed. The patient could bite in the mandibular
contact imprinting (B) after intervention. The clinical presentation
right molar as in other tooth positions, and the pulp was
of lateral occlusal contacts (C) after the occlusal veneer at
normal with the control tooth.
14 months follow-­up. The periapical radiograph (D) of tooth #16
The occlusal examination (Figure 3E,F) at centric oc- after the occlusal veneer at 14 months follow-­up. The X-­ray films
clusal contact and lateral occlusal movement at 6 months revealed normal width of the periodontal ligament and without
showed a uniform and stable state of contact. The clinical periapical lesion.
occlusal examination at centric occlusal contact and lat-
eral occlusal movement and radiological examination at was complete and continuous and had perfect marginal
14 months are shown in Figure 4. After being treated with adaptation with the preparation. No occlusal interferences
occlusal veneer for 14 months, the edge of the prosthesis and parafunction were observed. A periapical radiograph
WANG et al.
of tooth #16 also revealed a uniform periodontal ligament
space associated with this tooth.
3 | DI S C USSION
Studies on managing a cracked tooth are rarely reported,
making clinical decisions more difficult. Common symp-
toms of a cracked tooth include pain on release after bit-
ing, pain on biting, and thermal sensitivity.4 However,
judging pain originating from Aδ and C fibers results in a
subjective experience of a sharp and prickling pain, which
is challenging to locate because of a high degree of con-
vergence from pulp tissue and the lack of proprioceptive
information provided.13 These results suggested that the
teeth should be carefully examined to accurately identify
the final offending tooth, especially when the cracks are
indiscernible.
In the present study, the patient's primary complaint
was pain associated with biting hard food in the man-
dibular right molar region. After performing a detailed
clinical and radiological examination, a cracked tooth
with vital pulp (#16 tooth) was located by visual inspec-
tion and biting pain. As previously reported, most pa-
tients can locate the offending teeth in the maxillary or
mandible based on subjective symptoms, while diagno-
sis remains challenging for certain cases (these patients
cannot identify the position of the tooth).14 Biting and
thermal pain could be explained by the hydrodynamic
theory, which is based on the concept that the rapid
movement of dentinal fluid in the dentinal tubules stim-
ulates mechanoreceptors near the odontoblast cell body
and then activates the sensory nerve fibers in the dentin-­
pulp complex.
Currently, cuspal coverage restoration is the corner-
stone in managing cracked teeth.15 Cusp coverage, such
as a full crown, removes the steep cuspal inclines, thus
eradicating the phenomenon of wedge opening and de-
creasing the stress intensity factor at the crack tip. Yet,
a 6-­year follow-­up study revealed that 20% of crowned
cracked teeth with reversible pulpitis still require fur-
ther root canal treatment.12 Vital teeth restored by the
crown are also at a certain risk of applying RCT in
the future because of pulp stimulus after preparation.
Compared with a full coverage crown, the main advan-
tages of occlusal veneer are simple preparation and no
need to restrict clinical crown height because of bond-
ing to retention.9–­11 In our study, the patient's biting
pain was relieved after 1 week of occlusal veneer resto-
ration. Moreover, the #16 tooth kept a vital pulp state
and was asymptomatic with percussion and biting test
with a small cotton ball until follow-­up at 14 months.
Yet, longer-­ term follow-­up is needed to confirm the
   | 5 of 6
clinical and radiographic outcomes. Also, this tooth may
still require root canal treatment in the future, as long-­
term follow-­up (>5 years) regarding the management of
cracked tooth syndrome via occlusal veneers has not yet
been established in the literature.
4 | CONC LUSION
The occlusal veneer is a feasible, effective, and mini-
mally invasive therapy for protecting vital cracked teeth.
Nevertheless, multicenter prospective studies with ex-
tended follow-­up time and larger sample sizes are needed
to confirm the effectiveness of the occlusal veneer for the
vital cracked teeth.
AUTHOR CONTRIBUTIONS
Mengke Wang: Conceptualization; data curation; formal
analysis; investigation; methodology; project administra-
tion; visualization; writing –­original draft; writing –­re-
view and editing. Yingying Hong: Conceptualization;
data curation; formal analysis; funding acquisition; inves-
tigation; methodology; project administration; resources;
software; writing –­review and editing. Xiaomei Hou:
Conceptualization; investigation; methodology; project ad-
ministration; visualization. Yinfei Pu: Conceptualization;
data curation; formal analysis; funding acquisition; inves-
tigation; methodology; project administration; writing –­
original draft; writing –­review and editing.
FUNDING INFORMATION
None.
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest to disclose.
DATA AVAILABILITY STATEMENT
All authors gave their final approval and agreed to be ac-
countable for all aspects of the work.
ETHICS STATEMENT
Institutional review board/ethics committee approval
was obtained from the Institutional Review Board of the
Peking University School and Hospital of Stomatology
(PKUSSIRB-­202272008).
CONSENT STATEMENT
Written informed consent was obtained from the patient
to publish this report in accordance with the journal's pa-
tient consent policy.
INFORMED CONSENT
The patient has consented to the submission of the case.
6 of 6 |    WANG et al.
PERMISSION TO REPRODUCE MATERIAL
FROM OTHER SOURCES
Not included.
CLINICAL TRIAL REGISTRATION
This study was registered on the webpage of Chinese
Clinical Trial Registry and approved by their Institutional
Review Board (ChiCTR2200057462, 13/03/2022).
ORCID
Yinfei Pu https://orcid.org/0000-0002-5764-5438
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How to cite this article: Wang M, Hong Y, Hou
X, Pu Y. Management and prognosis of a vital
cracked tooth by occlusal veneer for 14 months: A
case report. Clin Case Rep. 2023;11:e7714.
doi:10.1002/ccr3.7714