Journal of the Formosan Medical Association 121 (2022) 247e257

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Original Article

Cracked teeth: Distribution and survival at 6

months, 1 year and 2 years after treatment
Wan-Chuen Liao a,b, Yi-Ling Tsai a,b, Kuan-Liang Chen c,
Brooke Blicher d, Shu-Hui Chang e, Sin-Yuet Yeung f,
Mei-Chi Chang f,g,**, Jiiang-Huei Jeng a,b,h,i,*

a
School of Dentistry, College of Medicine, National Taiwan University, Taipei, Taiwan
b
Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
c
Department of Dentistry, Chi-Mei Medical Center, Tainan, Taiwan
d
Harvard School of Dental Medicine, Boston, MA, USA
e
School of Public Health, National Taiwan University, Taipei, Taiwan
f
Department of Dentistry, Chang Gung Memorial Hospital, Taipei, Taiwan
g
Chang Gung University of Science and Technology, Kwei-Shan, Taoyuan, Taiwan
h
School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
i
Department of Dentistry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Received 17 February 2021; received in revised form 15 March 2021; accepted 22 March 2021

KEYWORDS Background/purpose: The unpredictable condition of cracked teeth warrants further investi-
Cracked tooth; gation and clinical experiences. The purpose of this study was to collect and record data on
Clinical demographics, clinical characteristics, different treatment modalities and survival of cracked
characteristic; teeth at 6-month, 1-year and 2-year recalls.
Treatment modality; Methods: 77 cracked teeth from 65 patients were included. Data on demographics, clinical pa-
Prognosis; rameters, treatment modalities and recall were collected. Binomial, multinomial and chi
Survival rate square tests were used for statistical analysis.
Results: Most cracked teeth occurred in patients greater than 40 years old (p < 0.01). Cracked
teeth themselves were most often molars (79.22%; p < 0.01), a non-terminal tooth in the arch
(62.34%; p < 0.05) and nonendodontically-treated teeth (94.81%; p < 0.01). Cracked teeth exhib-
ited pain to percussion (63.64%, p < 0.05) or biting (74.03%; p < 0.01), and no or only positive
mobility (76.62%; p < 0.01). Cracks were most often oriented in the mesiodistal direction
(68.83%; p < 0.01). Higher survival rates were noted in cracked teeth lacking pre-operative pain
to palpation or spontaneous pain, and with no or only positive mobility at 6-month and 1-year re-
calls. In vital cracked teeth, higher survival rates were noted in teeth lacking pre-operative pain
to palpation and with no or only positive mobility at 2-year recalls.
Conclusion: The absence of pre-operative palpation discomfort, spontaneous pain and minimal
mobility, as well as the presence of pulp vitality were associated with higher survival rates of

* Corresponding author. School of Dentistry, National Taiwan University Medical College, No 1, Chang-Te Street, Taipei, Taiwan.
** Corresponding author. Chang Gung University of Science and Technology, 261, Wen-Hua 1st Road, Kwei-Shan, Taoyuan, 33303, Taiwan.
E-mail addresses: mcchang@mail.cgust.edu.tw (M.-C. Chang), jhjeng@ntu.edu.tw, jhjeng@kmu.edu.tw (J.-H. Jeng).

https://doi.org/10.1016/j.jfma.2021.03.020
0929-6646/Copyright ª 2021, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 W.-C. Liao, Y.-L. Tsai, K.-L. Chen et al.
cracked teeth at all recall times. Results are useful for diagnosis and outcomes-based treat-
ment planning of cracked teeth.
Copyright ª 2021, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Introduction
Cracked teeth are defined as teeth with fractures present
in the vertical or horizontal direction involving the crown
and/or extending to root structure.1e3 Crown-originating
fracture lines may propagate through tooth structure,
and extend to subgingival levels of unknown depth.
Sometimes, fractures may communicate with the pulp
tissue and periodontium.4 Crack lines themselves are
usually directed mesiodistally,5 and are usually in a
centered and apical position compared to the occlusal
surface. With greater apical extension, cracked teeth may
lead to pulpal or periapical pathosis.6 Predisposing factors
may be categorized as naturally occurring (ie. steep cus-
pal inclination, bruxism, clenching, attrition and abra-
sion), pronounced intra-oral temperature fluctuation or
iatrogenic (ie. poor cavity design of restoration, wrong
selection of restorative materials, historic application of
rotary instruments and access cavity preparation).7e9
Cracks may be associated with dietary habits. Yang
et al. postulated that pulpitis and pulp necrosis in cracked
teeth occurs secondary to patient preference for fibrous
and hard foods in a Korean population.10
The incidence of cracked teeth is reported to be popular
in male, 40e50 y/o patients, in molars and maxillary arch
(molar, premolar) or mandibular molars.4,9 But crack teeth
are more prevalent for 50e59 y/o patients and in lower
molars of Korean patients.10 Some authors also report that
males and females are equally affected,11 whereas others
find a greater predisposition in females.4,12 Most report a
greater prevalence in patients over 40 years old and in
mandibular molars.2,4,13 Maxillary molars and premolars
have a similar incidence of cracks, while the mandibular
premolars are least susceptible.14 Cracked teeth may be
found in both intact and heavily restored teeth.3,5,15
Classical presentations include unexplained sensitivity to
cold, sudden pain on mastication, particularly of hard or
crunchy foods, or pain on release of biting pressure.2,5,14,16
Cracked teeth may have normal or deep periodontal prob-
ing depths.5 As bacteria and associated toxins penetrate into
the pulp chamber, discomfort and eventual necrosis is ex-
pected.17,18 The symptoms of cracked teeth varied from mild
to severe spontaneous pain, presenting as irreversible pulpi-
tis, pulp necrosis, apical periodontitis or apical abscess.5
Despite the above patterns, clinical symptoms are gener-
ally not diagnostic for cracked teeth, and it has proven a
challenging and perplexing diagnosis. More often than not,
they are not apparent on visual inspection. The application of
loupes, a surgical operating microscope or fiber-optic devices
may be useful in magnification and transillumination. A sharp
probe is rarely helpful in detecting the fracture line. Removal
of existing restorations or staining of the tooth may aid in
crack line identification. Symptoms may be induced using
248
diagnostic tools, including orange wood sticks, cotton wool
rolls, rubber abrasive wheels, or the head of a number 10
round bur in a handle of cellophane tape, etc. Whereas crack
lines themselves usually cannot be detected radiographically,
radiographs are needed for detecting dental caries, pulpal/
periapical and periodontal pathosis.
Early diagnosis of cracked teeth is important. Restorative
interventions can limit fracture propagation and exacerba-
tion of associated pulpal disease. Treatment strategies vary
depending upon the location and depth of the crack. Out-
comes are classified based on involvement of marginal
ridges, dental pulp and pulpal floor.19 Teeth with complete
mesiodistal fractures, or fractures that cannot be removed
by gingivoplasty or alveoplasty are considered hopeless.19
Though several publications report on the incidence,
distribution, clinical features, treatment strategies and
outcomes of cracked teeth, their unpredictable nature
warrants further investigation and clinical experience. We
hypothesize that patient demographics, pre-operative
clinical characteristics, and differing treatment modalities
may affect the outcomes of cracked teeth. We analyzed
clinical parameters and treatment, looking for associations
with prognosis, as measured by survival of the enrolled
cracked teeth at 6-month, 1-year and 2-year intervals.
Materials and methods
Patient inclusion
This study was approved by the Ethics Committee of the
National Taiwan University Hospital (202006070RIND). A
total of 77 cracked teeth from 65 patients treated in the
dental department were collected between 2014 and 2018.
The inclusion criteria for cracked teeth involved at least 1
of the following methods: crack line clearly visualizable via
clinical examination (with or without microscope magnifi-
cation), radiographic image, or after tooth extraction. The
diagnosis was confirmed by two endodontists. Clinical ex-
amination records and radiographic images were reviewed
following crack verification. Cracked teeth lacking suffi-
cient clinical data or presenting with another type of tooth
fracture (e.g., craze lines, fractured cusps, split tooth or
vertical root fracture) were excluded.
Clinical parameters
For each case included, the following parameters were
recorded, based on several related studies.3,5,13,20
1. Demographic information
a. Gender
b. Age
 Journal of the Formosan Medical Association 121 (2022) 247e257
2. Clinical data
a. Tooth position
b. Terminal tooth in the arch (yes or no)
c. Tooth status (presence of intra-coronal restoration,
crown or intact tooth)
d. Prior root canal status (endodontically- or non-
endodontically-treated)
e. Pulp sensitivity test response (normal pulp, moderate
or severe cold sensitivity, non-responsive or
endodontically-treated)
f. Percussion pain (yes or no)
g. Palpation pain (yes or no)
h. Spontaneous pain (yes or no)
i. Acute abscess/swelling (yes or no)
j. Sinus tract (yes or no)
k. Probing depth (<5 mm or
5 mm)
l. Mobility (including , þ, Grade I or Grade II)
m. Biting pain (yes or no)
n. Direction of crack (mesiodistal, buccolingual or both)
o. Subgingival extension (yes or no)
p. Treatment method
i. Follow-up without intervention
ii. Composite resin filling
iii. Root canal treatment then permanent crown
fabrication (RCT/Crown)
iv. Provisional crown then permanent crown fabri-
cation (Prov./Crown)
v. Provisional crown followed by root canal treat-
ment (RCT) and permanent crown fabrication
(Prov./RCT/Crown)
vi. Stainless steel band placement then permanent
crown fabrication (S.S. band/Crown)
vii. Stainless steel band placement followed by RCT
and permanent crown fabrication (S.S.
band/RCT/Crown)
viii. Extraction
3. 6-month, 1-year and 2-year recall
a. Survived or failed: the cracked tooth was categorized as
“survived” if it was presented in the dental arch,
asymptomatic and functional. Otherwise, the tooth was
grouped as failed.
Statistical methods
Demographic and clinical examination data are presented
in the tables and figures as the number of cases and per-
centages. Statistical analyses were performed on R Studio
Version 0.99.902 (The R Foundation for Statistical
Computing, Vienna, Austria). Binomial and multinomial test
were used to evaluate the distribution pattern in the vari-
ables of cracked teeth. Chi square test was applied to
evaluate the relationship between the survival rate and the
potential outcome predictors. Differences were considered
significant at p < 0.05.
Results
Clinical characteristics of crack teeth
A total of 77 cracked teeth in 65 Chinese patients were
investigated and collected in this study. The demographic
249
and clinical data are presented in Table 1. Clinical pic-
tures of some representative cracked teeth were dis-
played in Fig. 1. There were 25 males (38.46%) and 40
females (61.54%) patients included in the study. Patients’
age ranged from 22 to 80 years old (average Z 54 years
old). Most of the cracked teeth occurred in patients
greater than 40 years old, and this was statistically sig-
nificant (p < 0.01). The study included 33 mandibular
molars (42.86%), 28 maxillary molars (36.36%) and 16
maxillary premolars (20.78%). Neither anterior teeth nor
mandibular premolars were present in the study. Cracks
most often occurred in molars (61 teeth, 79.22%;
p < 0.01), teeth that were not the terminal in the arch (48
teeth, 62.34%; p < 0.05) and nonendodontically-treated
teeth (73 teeth, 94.81%; p < 0.01). Results all showed
statistical significance. Equal cases were discovered in
restored (38 teeth, 49.35%) versus intact teeth (38 teeth,
49.35%). More cracks were present in vital teeth (42
teeth, 54.54%) than those with alternative pulp status.
The presence of pre-operative percussion pain (49 teeth,
63.64%, p < 0.05), no or only positive mobility (59 teeth,
76.62%; p < 0.01), biting pain (57 teeth, 74.03%;
p < 0.01), mesiodistal crack orientation (53 teeth, 68.83%;
p < 0.01), but a lack of palpation pain (57 teeth, 74.03%;
p < 0.01), abscess (65 teeth, 84.42%; p < 0.01) or sinus
tract (71 teeth, 92.21%; p < 0.01) showed statistically
significant associations with cracked teeth. No statisti-
cally significant associations were found in regards to
spontaneous pain, periodontal probing depth or sub-
gingival extension.
Treatment modalities
Treatment modalities in this study included regular follow-
up (21 teeth, 27.27%), composite resin filling (1 tooth,
1.30%), RCT/Crown (18 teeth, 23.38%), Prov./Crown (8
teeth, 10.39%), Prov./RCT/Crown (6 teeth, 7.79%), S.S.
band/Crown (2 teeth, 2.60%), S.S. band/RCT/Crown
(14 teeth, 18.18%) and extraction (7 teeth, 9.09%).
Survival of crack teeth
Statistics regarding recall data are shown in Table 2. At
6-month recall, 57 cases returned with 50 survived and 7
failed. At 1-year recall, 50 cases returned with 38 sur-
vived and 12 failed. At 2-year recall, 35 cases returned
with 22 survived and 13 failed. The recall rate was
74.03%, 64.94% and 45.45% respectively. The survival
rates were 87.72%, 76.00% and 62.86% at these three
time points.
The survived and failed case number and statistical
analysis at 6-month, 1-year and 2-year recall regarding
various parameters are shown in Table 3. Statistically
significantly higher survival rates were noted in cracked
teeth without palpation pain (p < 0.05), without sponta-
neous pain (p < 0.05) and with no or only positive mobility
(p < 0.05) at both 6-month and 1-year recalls. Similarly,
greater survival rates were present in vital cracked teeth
(p < 0.01) which were without palpation pain (p < 0.05)
and with no or only positive mobility (p < 0.05) at 2-year
recall.
 W.-C. Liao, Y.-L. Tsai, K.-L. Chen et al.

Table 1 Distribution and statistical analysis of demographic and clinical data on cracked teeth collected in the study. Binomial
and polynomial tests were used for statistical analysis of the difference among groups.
Category Case number (%) Statistical analysis p-value
case number (%)
Demography
Gender
Male 25 (38.46%) 25 (38.46%) 0.0817
Female 40 (61.54%) 40 (61.54%)
Age
20e29 1 (1.54%) 4 (6.16%) <0.01
30e39 3 (4.62%)
40e49 13 (20.00%) 61 (93.84%)
50e59 27 (41.53%)
60e69 16 (24.62%)
70e79 4 (6.15%)
80e89 1 (1.54%)
Clinical data
Tooth position
Maxillary anterior 0 (0.00%) 0 (0.00%) <0.01
Mandibular anterior 0 (0.00%)
Maxillary premolar 16 (20.78%) 16 (20.78%)
Mandibular premolar 0 (0.00%)
Maxillary molar 28 (36.36%) 61 (79.22%)
Mandibular molar 33 (42.86%)
Terminal tooth in the arch
Yes 29 (37.66%) 29 (37.66%) 0.0395
No 48 (62.34%) 48 (62.34%)
Tooth status
Intracoronal restoration 38 (49.35%) 38 (49.35%) 1
(Resin/Porcelain/Gold/Amalgam)
Intact tooth 38 (49.35%) 38 (49.35%)
Crown (Provisional crown) 1 (1.30%)
Prior root canal status
Endodontically-treated 4 (5.19%) 4 (5.19%) <0.01
Nonendodontically-treated 73 (94.81%) 73 (94.81%)
Pulp vitality test
Normal pulp 21 (27.27%) 42 (54.54%) 0.4944
Moderate cold sensitivity 15 (19.48%)
Severe cold sensitivity 6 (7.79%)
Nonvital tooth 31 (40.27%) 35 (45.46%)
Endodontically-treated 4 (5.19%)
Percussion pain
Yes 49 (63.64%) 49 (63.64%) 0.0220
No 28 (36.36%) 28 (36.36%)
Palpation pain
Yes 20 (25.97%) 20 (25.97%) <0.01
No 57 (74.03%) 57 (74.03%)
Spontaneous pain
Yes 39 (50.65%) 39 (50.65%) 1
No 38 (49.35%) 38 (49.35%)
Abscess/Swelling
Yes 12 (15.58%) 12 (15.58%) <0.01
No 65 (84.42%) 65 (84.42%)
Sinus tract
Yes 6 (7.79%) 6 (7.79%) <0.01
No 71 (92.21%) 71 (92.21%)
Probing depth
<5 mm 38 (49.35%) 38 (49.35%) 1

5 mm 39 (50.65%) 39 (50.65%)

250
 Journal of the Formosan Medical Association 121 (2022) 247e257

Table 1 (continued )
Category Case number (%) Statistical analysis p-value
case number (%)
Mobility
e 52 (67.53%) 59 (76.62%) <0.01
þ 7 (9.09%)
Grade I 8 (10.39%) 15 (19.48%)
Grade II 7 (9.09%)
Biting pain
Yes 57 (74.03%) 57 (74.03%) <0.01
No 20 (25.97%) 20 (25.97%)
Direction of crack
Mesiodistal 53 (68.83%) 53 (68.83%) <0.01
Buccolingual 8 (10.39%) 24 (31.17%)
Both 16 (20.78%)
Subgingival extension
Yes 44 (57.15%) 44 (57.15%) 0.0764
No 28 (36.36%) 28 (36.36%)
Treatment
Follow-up 21 (27.27%) N/A
Composite resin filling 1 (1.30%)
RCT/Crown 18 (23.38%)
Prov./Crown 8 (10.39%)
Prov./RCT/Crown 6 (7.79%)
S.S. band/Crown 2 (2.60%)
S.S. band/RCT/Crown 14 (18.18%)
Extraction 7 (9.09%)
N/A: Not applicable.
Bold indicates the presence of statistically significant difference (p < 0.05).

Discussion reported elsewhere in the literature.12,21 This may reflect

Our study found more cracked teeth in female (61.54%)
rather than male patients (38.46%), though the difference
was not statistically significant. However, this is consistent
with a predilection for cracked teeth in female patients
higher dental care utilization or dental awareness among
female patients, or a lesser tendency of male patients to
report symptoms.3,12 However, another study reported that
males exhibited more cracks, they purported due to more
advanced development of masticatory muscles and greater

Figure 1 Various cracked teeth identified in the (a) maxillary molar, (b) maxillary molar, (c) maxillary premolar, (d) mandibular
molar, (e) mandibular molar under the magnification of microscope, (f) maxillary premolar, (g) maxillary molar and (h) maxillary
molar. (Black arrows indicated the cracks.)
251
 W.-C. Liao, Y.-L. Tsai, K.-L. Chen et al.
Table 2 The number of returned cases and the recall rate
and survival rate at 6-month recall, 1-year recall and 2-year
recall.
6-month 1-year 2-year
recall recall recall
Case number 57 50 35
Recall rate 74.03% 64.94% 45.45%
Survived case number 50 38 22
Failed case number 7 12 13
Survival rate 87.72% 76.00% 62.86%
biting force exerted.22 Gender-based differences were not
found in other studies where both genders appear to be
equally affected.3,5,15
Most cases in our study were older than 40 years old,
consistent with prior studies.9,10,15,23 This is presumed
secondary to age-related changes in the fatigue resistance
of dentin,24 loss of dentin elasticity, increased stress fa-
tigue over time, and less pliable supporting tissues.3,4,13
Cracked teeth were most often molars (79.22%) partic-
ularly mandibular molars (42.86%) in this study. Other
studies similarly report a higher prevalence in cracked
teeth in mandibular molars.25,26 This predilection for pos-
terior teeth may be explained by the increased ratio of bite
force in molars, premolars, and incisors, reported as 4:2:1,
and proximity to the temporomandibular joint (TMJ).23,27
Based on the lever effect, masticatory forces are greater
closer to the TMJ.13 Counter to this, in this study, most
cracked teeth were not the terminal tooth in the dental
arch, with statistically significant differences. Deeper
central fossae found in mandibular molars may be another
contributing factor, as the palatal cusps of the maxillary
molars may function as plungers, leading to structural fa-
tigue in opposing mandibular teeth.13,28
Other studies show a predilection for maxillary molars.
In a Korean study of 154 cracked teeth, a predilection was
found for maxillary molars.15 The authors surmised that the
mandibular molars were lingual-tilted, and the buccal cusps
acted as plunger cusps causing them to crack. Qing et al.
also reported a predisposition of unrestored maxillary mo-
lars to cracks.29 Ultimately, both maxillary and mandibular
molars may be susceptible to cracks.
The numbers of cracked teeth with or without restora-
tion (intact) was equivocal in this study. Many studies
report a high incidence of cracks in intact and unrestored
teeth.10,13,15 Thermal cycling and parafunctional habits are
proposed to be responsible for the generation of cracks in
intact teeth.23,30 Teeth with excursive interferences are
reported 2.3 times more likely to develop cracks secondary
to mastication and parafunction habits.31 Apart from dental
caries, cracks were proposed to be the main source of
pulpal infection and inflammation in teeth with relative
intact crowns.32
Another study reported cracked teeth more often in
heavily restored teeth.3 Seo et al. found that most cracked
teeth were previously restored (72.0%), whereas only 28.0%
were discovered in intact teeth without prior restorations.
The authors also found a relationship between the restor-
ative material and the presence of a crack. More cracks
252
were seen in teeth restored with amalgam and gold inlays
than those restored with resin and porcelain inlays.3 Non-
bonded restorations combined with sharp internal line an-
gles were proposed as contributors to the cracks. Occlusal
forces may be dispersed within the bonded restorative
materials reducing the risk of crack formation.33
This study found a statistically significant predilection
for nonendodontically-treated teeth and those with vital
pulp responses. As it was unknown the preoperative pulp
status of the endodontically-treated teeth, it is unclear if
the amount of the vital cracked teeth may be under-
estimated. Maintaining pulp vitality and choosing the
proper treatment modality are important in the manage-
ment of vital cracked teeth.
Most of the patients enrolled in this study presented
with pain to percussion and biting at statistically significant
levels. Pain on biting is proposed to be the most common
symptom of cracked teeth.4,11,34 One study of 370 patients
with cracked teeth found that all reported pain on the bite
test.4 However, Hilton et al. found a greater frequency of
cold hypersensitivity, followed by pain on biting.35 Masti-
catory pain is presumed due to dentinal fluid flow resulted
from the movement between the cracked segments, a
concept proposed by Brännström as the “Hydrodynamic
theory of dentin sensitivity”.2,36,37 Other symptoms such as
pain to palpation, abscess/swelling and sinus tracts were
not evidently associated with cracked teeth in this study.
Treatment recommendations in this study followed the
severity and preoperative pulpal/periapical diagnosis of the
cracked teeth investigated. If cracks were almost not
visible or incipient, regular follow-up and/or composite
resin fillings were advised. If cracks involved the pulpal
tissue creating symptoms of irreversible pulpitis, pulp ne-
crosis or root canal therapy was previously initiated, RCT
was performed. Placement of a provisional crown or
stainless-steel band for protection were suggested, but
depended on the patient’s willingness to pursue. If cracked
teeth were asymptomatic or exhibited reversible pulpitis,
then a provisional crown or stainless steel band was placed
for observation of symptoms. Resolution of symptoms or
after RCT preceded fabrication of the permanent pros-
thesis. Immediate extraction was suggested if the cracked
teeth were deemed unrestorable.
The above treatment protocols are consistent with those
proposed in the literature.5 For all initial treatments, prior
restorative materials are removed in order to confirm the
location and extent of cracks. In the diagnostic stage,
placement of copper or stainless steel bands, or stainless
steel or provisional crowns are suggested.38 Banding or
provisional crowns provide protection to the cracked tooth,
aiming to prevent movement and further progression of the
crack itself, as well as time to monitor a change in symp-
toms.39,40 Some cracks and fractures can be successfully
managed using direct restorative materials.41
Even with the diagnosis of reversible pulpitis, 21% of
cracked teeth ultimately require RCT.42 In our study,
49.35% of the cracked teeth eventually received RCT. This
relatively high proportion of patients receiving RCT is pre-
sumed due to the time elapsed before referral or late
diagnosis.5 Although a cusp-reinforced restoration does not
guarantee success, it is still beneficial and recommended in
the majority of cases.6 Krell and Rivera reported a low
 Table 3 The survived and failed case number and statistical analysis at 6-month, 1-year and 2-year recalls.
Category Case 6-month recall 1-year recall 2-year recall
number (%) Survived case Failed case p value Survived Failed case p value Survived Failed case p value
number (%) number (%) case number (%) case number (%)
number (%) number (%)
Demography
Gender
Male 25 (38.46%) 19 (86.36%) 3 (13.64%) 1 14 (70.00%) 6 (30.00%) 0.6361 10 (58.82%) 7 (41.18%) 0.8966
Female 40 (61.54%) 31 (88.57%) 4 (11.43%) 24 (80.00%) 6 (20.00%) 12 (66.67%) 6 (33.33%)

Journal of the Formosan Medical Association 121 (2022) 247e257

Age
20e29 1 (1.54%) 29 (80.56%) 7 (19.44%) 0.0820 23 (71.88%) 9 (28.12%) 0.5716 11 (52.38%) 10 (47.62%) 0.2248
30e39 3 (4.62%)
40e49 13 (20.00%)
50e59 27 (41.53%)
60e69 16 (24.62%) 21 (100.00%) 0 (0.00%) 15 (83.33%) 3 (16.67%) 11 (78.57%) 3 (21.43%)
70e79 4 (6.15%)
80e89 1 (1.54%)
Clinical data
Tooth position
Maxillary anterior tooth 0 (0.00%) 0 (0.00%) 0 (0.00%) 0.6622 0 (0.00%) 0 (0.00%) 0.4795 0 (0.00%) 0 (0.00%) 0.1501
Mandibular anterior tooth 0 (0.00%)
253

Maxillary premolar tooth 16 (20.78%) 14 (93.33%) 1 (6.67%) 11 (84.62%) 2 (15.38%) 9 (81.82%) 2 (18.18%)
Mandibular premolar tooth 0 (0.00%)
Maxillary molar tooth 28 (36.36%) 36 (85.71%) 6 (14.29%) 27 (72.97%) 10 (27.03%) 13 (54.17%) 11 (45.83%)
Mandibular molar tooth 33 (42.86%)
Terminal tooth in the arch
Yes 29 (37.66%) 19 (95.00%) 1 (5.00%) 0.4188 13 (72.22%) 5 (27.78%) 0.9012 7 (53.85%) 6 (46.15%) 0.6269
No 48 (62.34%) 31 (83.78%) 6 (16.22%) 25 (78.13%) 7 (21.87%) 15 (68.18%) 7 (31.82%)
Tooth status
With restoration 38 (49.35%) 23 (88.46%) 3 (11.54%) 1 16 (76.19%) 5 (23.81%) 1 8 (61.54%) 5 (38.46%) 1
(Resin/Porcelain/
Gold/Amalgam)
Crown (Provisional crown) 1 (1.30%)
Intact tooth 38 (49.35%) 27 (87.10%) 4 (12.90%) 22 (75.86%) 7 (24.14%) 14 (63.64%) 8 (36.36%)
Prior root canal status
Endodontically treated 4 (5.19%) 3 (100.00%) 0 (0.00%) 1 2 (66.67%) 1 (33.33%) 1 1 (50.00%) 1 (50.00%) 1
Nonendodontically treated 73 (94.81%) 47 (87.04%) 7 (12.96%) 36 (76.60%) 11 (23.40%) 21 (63.64%) 12 (36.36%)
Pulp vitality test
Normal pulp 21 (27.27%) 31 (93.94%) 2 (6.06%) 0.2044 26 (86.67%) 4 (13.33%) 0.068 19 (82.61%) 4 (17.39%) <0.01
Moderate cold sensitivity 15 (19.48%)
Severe cold sensitivity 6 (7.79%)
(continued on next page)
 Table 3 (continued )
Category Case 6-month recall 1-year recall 2-year recall
number (%) Survived case Failed case p value Survived Failed case p value Survived Failed case p value
number (%) number (%) case number (%) case number (%)
number (%) number (%)
Nonvital tooth 31 (40.27%) 19 (79.17%) 5 (20.83%) 12 (60.00%) 8 (40.00%) 3 (25.00%) 9 (75.00%)
Endodontically treated 4 (5.19%)
Percussion pain
Yes 49 (63.64%) 31 (81.58%) 7 (18.42%) 0.1165 22 (70.97%) 9 (29.03%) 0.4696 13 (56.52%) 10 (43.48%) 0.4806
No 28 (36.36%) 19 (100.00%) 0 (0.00%) 16 (84.21%) 3 (15.79%) 9 (75.00%) 3 (25.00%)
Palpation pain
Yes 20 (25.97%) 8 (57.14%) 6 (42.86%) <0.01 6 (46.15%) 7 (53.85%) 0.0107 3 (30.00%) 7 (70.00%) 0.0310
No 57 (74.03%) 42 (97.67%) 1 (2.33%) 32 (86.49%) 5 (13.51%) 19 (76.00%) 6 (24.00%)
Spontaneous pain

W.-C. Liao, Y.-L. Tsai, K.-L. Chen et al.

Yes 39 (50.65%) 19 (76.00%) 6 (24.00%) 0.0481 11 (55.00%) 9 (45.00%) 0.0124 9 (50.00%) 9 (50.00%) 0.2041
No 38 (49.35%) 31 (96.88%) 1 (3.12%) 27 (90.00%) 3 (10.00%) 13 (76.47%) 4 (23.53%)
Abscess
Yes 12 (15.58%) 5 (62.50%) 3 (37.50%) 0.0779 4 (50.00%) 4 (50.00%) 0.1535 1 (20.00%) 4 (80.00%) 0.1005
No 65 (84.42%) 45 (91.84%) 4 (8.16%) 34 (80.95%) 8 (19.05%) 21 (70.00%) 9 (30.00%)
Sinus tract
Yes 6 (7.79%) 4 (100.00%) 0 (0.00%) 1 3 (75.00%) 1 (25.00%) 1 1 (50.00%) 1 (50.00%) 1
254

No 71 (92.21%) 46 (86.79%) 7 (13.21%) 35 (76.09%) 11 (23.91%) 21 (63.64%) 12 (36.36%)

Probing depth
<5 mm 38 (49.35%) 26 (86.67%) 4 (13.33%) 1 20 (74.07%) 7 (25.93%) 0.9894 10 (58.82%) 7 (41.18%) 0.8966

5 mm 39 (50.65%) 24 (88.89%) 3 (11.11%) 18 (78.26%) 5 (21.74%) 12 (66.67%) 6 (33.33%)
Mobility
e 52 (67.53%) 45 (97.83%) 1 (2.17%) <0.01 34 (85.00%) 6 (15.00%) 0.0103 20 (74.07%) 7 (25.93%) 0.0352
þ 7 (9.09%)
Grade I 8 (10.39%) 5 (45.45%) 6 (54.55%) 4 (40.00%) 6 (60.00%) 2 (25.00%) 6 (75.00%)
Grade II 7 (9.09%)
Biting pain
Yes 57 (74.03%) 37 (86.05%) 6 (13.95%) 0.8371 27 (75.00%) 9 (25.00%) 1 16 (61.54%) 10 (38.46%) 1
No 20 (25.97%) 13 (92.86%) 1 (7.14%) 11 (78.57%) 3 (21.43%) 6 (66.67%) 3 (33.33%)
Direction of crack
Mesiodistal 53 (68.83%) 37 (88.10%) 5 (11.90%) 1 28 (75.68%) 9 (24.32%) 1 18 (66.67%) 9 (33.33%) 0.6597
Buccolingual 8 (10.39%) 13 (86.67%) 2 (13.33%) 10 (76.92%) 3 (23.08%) 4 (50.00%) 4 (50.00%)
Both 16 (20.78%)
Subgingival extension
Yes 44 (57.15%) 27 (79.41%) 7 (20.59%) 0.0559 20 (66.67%) 10 (33.33%) 0.12 12 (52.17%) 11 (47.83%) 0.1492
No 28 (36.36%) 23 (100.00%) 0 (0.00%) 18 (90.00%) 2 (10.00%) 10 (83.33%) 2 (16.67%)
 Journal of the Formosan Medical Association 121 (2022) 247e257

incidence of only 4% of cracked teeth exhibiting progression

1 of cracked-associated interproximal periodontal destruc-
tion following crown fabrication.42 Preventive measures
including occlusal adjustments to reduce the cuspal in-
clinations and height may relieve the stress on cracked
2 (18.18%)

4 (23.53%) teeth.7 The placement of an acrylic splint is further sug-

gested to prevent crack propagation in patients exhibiting
parafunctional habits.43
Different treatment strategies are suggested for cracked
teeth with pulpal necrosis, termed “fracture necrosis”.44
13 (76.47%)

Extraction is recommended for teeth with a questionable

9 (81.82%)

prognosis.44 However, Krell and Caplan found that cracked

teeth can be maintained in the absence of periodontal
N/A

probing depths
5 mm and with expedient crown place-

ment following RCT.26
A consensus is lacking for the management of cracked
teeth. Multidisciplinary management of cracked teeth
1

often includes endodontic, periodontal, orthodontic, pros-

thodontic and surgical strategies.45 Clinicians should inform
patients of the expected prognosis and provide treatment
2 (12.50%)

3 (11.11%)

alternatives.6 In our study, preservation of the cracked

tooth was the main goal.
Recall rates were 74.03%, 64.94% and 45.45% at 6-month,
1-year and 2-year follow-ups in this study. In Krell and
Caplan’s study, only 27% of the treated patients returned
14 (87.50%)

24 (88.89%)

after 1 year.26 Other long-term outcomes studies have pre-

sented recall rates of 50% and 43%.46,47 Thus, an advantage
N/A

and added value of this study is that higher recall rate over
other similar studies. Survival rates were 87.72%, 76.00% and
62.86% respectively at these three time periods. Variable
survival rates are found throughout the literature. In Krell
N/A

and Caplan’s study, 296 (82%) out of 363 cracked teeth

receiving RCT were classified as success after 1 year.26 Kang
et al. reported a 90.0% survival rate of cracked teeth
receiving RCT at 2 years.13 Upon 5-year follow-up of 84 pa-
0 (0.00%)

0 (0.00%)

tients with cracked teeth, 77 teeth survived (92%) and 7

teeth (8%) were extracted.47 This variability in survival rates
among different studies is presumed secondary to variations
in diagnostic criteria and adopted treatment strategies.
16 (100.00%)

34 (100.00%)

In our study, statistically significantly higher survival

rates were noted in cracked teeth without pain to palpa-
tion, spontaneous pain, and with no or only positive
mobility at both 6-month and 1-year recalls. Other studies
N/A

show improved prognosis when cracks are not visible, do

not extend to chamber floor, and are lacking subjective
21 (27.27%)

18 (23.38%)

14 (18.18%)

pain.6 Mild mobility suggests a relatively intact supporting

8 (10.39%)
1 (1.30%)

6 (7.79%)
2 (2.60%)

7 (9.09%)

attachment apparatus around the cracked tooth, leading to

better outcomes. Greater survival rates were found in vital
cracked teeth (p < 0.01), presenting without pain to
palpation (p < 0.05), and with no or only positive mobility
(p < 0.05) at 2-year recall. Loss of pulp vitality may pose a
S.S. band/RCT/Crown

negative effect on the prognosis of cracked tooth, consis-

tent with our study.14 Thus, early diagnosis of cracks and
Prov./RCT/Crown

maintenance of pulp vitality is important in tooth survival.

S.S. band/Crown

In conclusion, higher survival rates of cracked teeth

N/A: Not applicable.
Prov./Crown

were significantly associated with pain to palpation, spon-

RCT/Crown
Composite

Extraction

taneous pain, no or only positive mobility and with vital

Follow-up
Treatment

filling

pulps. The unique and value of our study provides the

resin

survival rate of cracked teeth with different treatment

considerations at 6-month, 1-year and 2-year recalls. More
clinical cases should be collected for further detailed
evaluation and survival rate analysis.

255
 W.-C. Liao, Y.-L. Tsai, K.-L. Chen et al.
Declaration of competing interest
The authors have no conflicts of interest relevant to this
article.
Acknowledgement
This study is supported by grants from National Taiwan
University Hospital (NTUH-110-S4815) and Ministry of Sci-
ence and Technology (MOST104-2314-B-255- 010-MY3,
MOST106-2314-B-002-033-MY2, MOST106-2314-B-002-034-
MY2, MOST107-2314- B-255-009-MY3, MOST107-2314-B-255-
008-MY2, MOST108-2314 -B-002-043-MY3), Taipei, Taiwan.
The authors declare no conflict of interest for this
manuscript.
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