The Effect of Single versus Multiple-stage Restorative Approaches on the Pulp Outcomes of Symptomatic Vital Cracked Teeth: A Systematic Review and Meta-analysis

Introduction: This systematic review aimed to compare single-stage treatment (SST) and multiple-stage treatment (MST) regarding pulp survival, pulp success, and tooth survival in symptomatic vital cracked teeth and to assess the influence of secondary interventions and baseline factors on pulp outcomes. Methods: Electronic searches were conducted in PubMed, Scopus, Web of Science, Cochrane Library, and “Gray Literature” through December 3, 2024, supplemented by hand searching. Clinical studies reporting pulp survival of permanent symptomatic vital cracked teeth with ≥1-year follow-up after complete SST or MST were included. Risk of bias was evaluated using the Newcastle-Ottawa Scale and the Revised Cochrane risk-of-bias tool. A single-arm random-effects meta-analysis was performed. The certainty of the body of evidence was assessed via the Grading of Recommendations Assessment, Development and Evaluation approach. Results: Fourteen cohort studies qualified. No significant difference was observed between SST and MST for 1- or 2-year pulp survival and 1-year pulp success (P > .05). However, SST with indirect restorations demonstrated significantly higher pulp success than MST with indirect (P < .05) and SST with direct (P < .001). Indirect onlays exhibited superior pulp outcomes compared to crowns (P < .05). Direct restorations were comparable to onlays for pulp survival (P > .05) but inferior for pulp success (P < .001). Short duration of interim treatment (1–2 weeks) yielded greater pulp success than long duration (2–3 months) (P < .05). One-year tooth survival was consistently high (96.1%–100%). The certainty of evidence was graded as very low due to the inclusion of observational studies and substantial between-study heterogeneity. Conclusions: This review suggests with very low level of certainty that SST with indirect restorations may improve pulp success over MST. Onlays outperform crowns, while direct restorations may not fully alleviate symptoms. Short interim treatment duration is preferable in MST. Timely intervention is critical for tooth survival.