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Operative Dentistry, 2013, 38-3, E67-E75
Conservative Treatment of
Complicated Oblique
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Crown-root Fractures of
Molars: A Report of Five
Representative Cases
P Wang W He L Ni
Q Lu H Sun
Operative Dentistry 2013.38:E67-E75.
Clinical Relevance
Crown-root fractures of molars with extensive loss of tooth structure extending well below
the alveolar crest can be successfully treated with a conservative method.
SUMMARY loss of tooth structure. After the mobile crown-

The five cases presented here describe a con- root fragments were extracted, the remaining
servative treatment procedure for complicated crowns were restored at the juxtagingival
crown-root fractures of molars with extensive level. The follow-up time ranged from two
years, seven months, to four years. At the
Ping Wang, PhD, Department of Operative Dentistry & follow-up examinations, all of the teeth were
Endodontics, School of Stomatology, The Fourth Military
asymptomatic and had healthy clinical appear-
Medical University, Xi’an, Shaanxi, China
ances. There was no evidence of pockets relat-
Wenxi He, PhD, Department of Operative Dentistry &
ed to fractures. The results of these cases show
Medical University, Xi’an, Shaanxi, China that complete periodontal healing is possible
with conservative treatment of complicated
Longxing Ni, PhD, Department of Operative Dentistry &
Endodontics, School of Stomatology, The Fourth Military crown-root fracture of molars.
Qun Lu, PhD, Department of Operative Dentistry and INTRODUCTION
Endodontics, School of Stomatology, The Fourth Military A crown-root fracture is defined as a fracture
involving the enamel, dentin, and cementum. These
*Hantang Sun, PhD, Department of Operative Dentistry & fractures may be grouped, according to pulpal
involvement, into ‘uncomplicated’ and ‘complicated.’1
Crown-root fractures are usually oblique and involve
*Corresponding author: 145 West Changle Road, Xi’an,
Shaanxi 710032, China; e-mail: hantang@fmmu.edu.cn
both the crown and root, splitting the crown and
extending subgingivally to the root surface, and they
DOI: 10.2341/12-371-SR1
are often complicated by pulp exposure and exten-
E68 Operative Dentistry
sive loss of tooth structure. In contrast to other been treated by pulp mummification8 (also referred
traumatic injuries, in which the posterior teeth are to as ‘‘mortal amputation of the pulp,’’ in contradis-
rarely involved, crown-root fractures often include tinction to vital amputation) previously. The clinical
the molars and premolars. In the posterior teeth, the examination revealed a large occlusal-distal amal-
cause of crown-root fractures has been attributed to gam restoration on the mandibular left second
indirect trauma, including large-size restorations.2 molar, with a fracture running mesiodistally along
the margin of the restoration (Figure 1A). The
The treatment strategy for crown-root fractures is

fracture extended subgingivally, the buccal fragment
complex. It has been recommended that all loose
was mobile in the lateral direction, and there was no
fragments be removed to evaluate the extent of the
mobility of the lingual part. The tooth was nonre-
injury.2,3 Restoration of a tooth with a crown-root
sponsive to pulp vitality testing. The periodontal
fracture or a cervical root fracture is unfavorable and
examination disclosed an approximately 5-mm pock-
can be a difficult procedure when the fracture line
et on the distal surface of the silver amalgam
extends below the marginal bone level. Such a
restoration. Periapical radiography showed no signs
fractured tooth is often considered hopeless.4 Restor-
of periapical disease (Figure 1B). With the patient’s
ative and functional needs are balanced with the
consent, local anesthesia was administered, the
demands of the healthy periodontium. Placing the
mobile buccal segment and the silver amalgam
margin of the restoration in the biologic width
restoration were removed (Figure 1C), and a one-
frequently leads to chronic gingivitis, the loss of
visit root canal treatment was performed. The
clinical attachment, bony pockets, and gingival
remaining crown was temporarily restored with zinc
recession.5 Crown-root fractures extending well
oxide–eugenol–based cement applied supragingi-

below the alveolar crest can require surgical reposi- vally. No antibiotic was administered. Visual exam-
tioning of the tissues to expose the level of the ination of the extracted segment showed that the
fracture. Either surgical or orthodontic extrusion buccal surface comprised the cervical thirds of both
can also be performed to allow for better restoration the mesial and distal roots, that the fracture of the
of the fractured tooth.1,6,7 The choice of treatment is roots was oblique in pattern, and that the longest
primarily determined using exact information about distance from the cementoenamel junction of the
the site and the type of fracture, but the cost and segment to the apical level was roughly 5 mm
complexity of treatment can also be deciding fac- (Figure 1D).
tors.1
At the seven-day follow-up, the patient was
Andreasen and Andreasen1 described the conser- asymptomatic, buccal gingival healing of the tooth
vative treatment of various types of crown-root was observed, and the zinc oxide–eugenol cement
fractures. The most conservative treatment was the was removed (Figure 1E). A coronal restoration with
following: the loose fragment is removed as soon as composite resin (Z250, 3M ESPE, St. Paul, USA) was
possible after the injury, and the remaining crown is then placed at the juxtagingival level (Figure 1F). A
temporarily restored supragingivally. Once gingival metal crown was then constructed.
healing is observed, the coronal portion can be
At the three-year follow-up, the tooth was free of
restored at the juxtagingival level. Andreasen and
clinical symptoms, was functioning normally, and
Andreasen1 noted that this procedure should be
had a healthy clinical appearance (Figure 1G). The
limited to superficial fractures that do not involve
pocket probing depth was still approximately 5 mm
the pulp. The aim of the present report is to describe
on the distal aspect of the crown margin. The
a similar conservative treatment procedure for
radiographic examination showed a stable bone level
complicated crown-root fractures of molars and to
when compared with the prior film, with no signs of
discuss the treatment outcomes.
periapical disease (Figure 1H).
CASE REPORTS
Case 2
Case 1
A 46-year-old male patient presented at the end-
A 47-year-old male patient presented at the endodontic clinic with a cracked mandibular right first
odontic clinic with a cracked mandibular left second molar. He said he felt the tooth had cracked two days
molar. He reported that he felt the tooth had cracked earlier when he chewed food. From the dental
four days earlier when he chewed food, and a history, it was learned that the tooth had been
toothache followed when chewing further. From the treated by pulp mummification previously. The
dental history, it was learned that the tooth had clinical examination revealed a large mesial-occlusal
Wang & Others: Treatment of Complicated Crown-root Fractures E69
Figure 1. Case 1. (A) A fracture running mesiodistally along the margin of the restoration on the mandibular left second molar (the arrow indicates
the fracture). (B) Preoperative radiograph. (C) Clinical appearance after the fractured segment was extracted. (D) Fractured buccal segment. (E)
Buccal gingival healing was observed at seven days after zinc oxide–eugenol cement was removed. (F) Resin composite restoration at the
juxtagingival level. (G) Buccal view at the three-year follow-up after insertion of the crown. (H) Three-year radiographic follow-up.
amalgam restoration on the mandibular right first and no signs of periapical disease (Figure 2B). With
molar, with a fracture running from the mesiolin- the patient’s consent, local anesthesia was adminis-
gual surface to the distal surface along the margin of tered, the mobile lingual segment and the silver
the restoration, separating the tooth into two amalgam restoration were removed, and a one-visit
distinct components (Figure 2A). The fracture ex- root canal treatment was performed. The remaining
tended subgingivally. The lingual fragment was crown was restored temporarily with zinc oxide–
mobile in the lateral direction, and there was no eugenol–based cement applied supragingivally (Fig-
mobility of the buccal part. The tooth was nonre- ure 2C). No antibiotic was administered. The visual
sponsive to pulp vitality testing. No pockets around examination showed that the lingual surface of the
the tooth were detected. Periapical radiography extracted segment comprised the cervical thirds of
showed a normal periodontal ligament of the tooth both the mesial and distal roots, that the fracture of
Figure 2. Case 2. (A) A fracture running from the mesiolingual surface to the distal surface along the margin of the restoration on the mandibular first
right molar (the arrow indicates the fracture). (B) Preoperative radiograph. (C) The remaining crown temporarily restored supragingivally. (D) Fractured
lingual segment. (E) Ten days after the lingual fragment was extracted. (F) Resin composite restoration at the juxtagingival level. (G) Lingual view at
the two-year, seven-month follow-up after insertion of the crown. (H) Two-year, seven-month radiographic follow-up.
the roots was oblique in pattern, and that the longest composite resin (Z250, 3M ESPE) was then placed at
distance from the cementoenamel junction of the the juxtagingival level (Figure 2F). A porcelain fused
segment to the apical level was roughly 5 mm to the metal crown was chosen to restore the tooth.
(Figure 2D). At the two-year, seven-month follow-up, the tooth
At the ten-day follow-up, the patient was asymp- was free of clinical symptoms, was functioning
tomatic, and the soft tissues were healthy (Figure normally, and had a healthy clinical appearance
2E). The zinc oxide–eugenol cement was removed, a (Figure 2G). No pockets were observed around the
1.3-mm–thick glass fiber–composite post (Produits tooth. The radiographic examination revealed a
Dentaires SA, Vevey, Switzerland) was luted in the normal periodontal ligament of the tooth and no
mesiolingual canal, and a coronal restoration with signs of periapical disease (Figure 2H).
Figure 3. Case 3. (A) A fracture line running mesiodistally along the margin of the restoration on the maxillary left second molar. (B) Preoperative
radiograph. (C) The remaining crown temporarily restored supragingivally. (D) Fractured buccal segment. (E) Resin composite restoration at the
juxtagingival level. (F) Buccal view at two-year, eight-month follow-up after insertion of the crown. (G) Two-year, eight-month radiographic follow-up.
Case 3 signs of periapical disease (Figure 3B). With the

A 64-year-old female patient presented with a crown patient’s consent, local anesthesia was administered,
fracture of the maxillary left second molar. She said the mobile buccal segment and the silver amalgam
she felt the tooth had cracked the day before when restoration were removed, and a one-visit root canal
she chewed food. From the dental history, it was treatment was performed; two root canals (a buccal
learned that the tooth had been treated by pulp one and a lingual one) were detected and filled. The
mummification previously. The clinical examination remaining crown was temporarily restored with zinc
showed a large occlusal-distal amalgam restoration oxide–eugenol–based cement applied supragingi-
on the maxillary left second molar and a fracture line vally (Figure 3C). No antibiotic was administered.
running mesiodistally along the margin of the The visual examination showed that the buccal
restoration, separating the crown into buccal and surface of the extracted segment comprised the
lingual parts (Figure 3A). The buccal fragment was cervical third of the buccal root, that the fracture of
mobile in the lateral direction, there was no mobility the root was oblique in pattern, and that the longest
of the lingual part, and the tooth was nonresponsive distance from the cementoenamel junction to the
to pulp vitality testing. No pockets around the tooth apical level of the segment was approximately 5 mm
were detected. Periapical radiography revealed no (Figure 3D).
Figure 4. Case 4. (A) A fracture line running from the mesial surface to the distal side of a cavity of the maxillary right second molar (the arrow
indicates the fracture). (B) Fractured lingual segment. (C) Posts were luted in the lingual canal and the distobuccal canal individually. (D) Radiograph
taken immediately after insertion of the crown. (E) Lingual view at three-year, six-month follow-up after insertion of the crown. (F) Three-year, six-
month radiographic follow-up.
At the seven-day follow-up, the patient was tooth, and there was a fracture line running from the
asymptomatic, and the soft tissues were healthy. mesial surface to the distal side of the cavity of the
The zinc oxide–eugenol cement was removed, a 1.3- tooth (Figure 4A). The lingual fragment was mobile
mm–thick glass fiber–composite post (Produits Den- in the lateral direction, and the tooth was nonre-
tarires SA) was luted in the lingual canal, and a sponsive to pulp vitality testing. No pockets around
coronal restoration with composite resin (Z250, 3M the tooth were detected. Periapical radiography
ESPE) was then placed at the juxtagingival level revealed no signs of periapical disease. With the
(Figure 3E). A metal crown was chosen to restore the patient’s consent, local anesthesia was administered,
tooth. and the mobile lingual segment was removed; this
At the two-year, eight-month follow-up, the tooth was followed by a one-visit root canal treatment. The
was free of clinical symptoms, was functioning files could not reach working length because the pulp
normally, and had a healthy clinical appearance canal space was totally obliterated, and the root
(Figure 3F). The pocket probing depth did not exceed canals were underfilled. The remaining crown was
3 mm. The radiographic examination showed a temporarily restored with zinc oxide–eugenol–based
stable bone level when compared with the prior film cement applied supragingivally. No antibiotic was
and no signs of periapical disease (Figure 3G). administered. The visual examination showed that
the lingual surface of the extracted segment com-
Case 4 prised the cervical third of the lingual root, that the
fracture of the root was oblique in pattern, and that
A 69-year-old male patient presented with a crown
the longest distance from the cementoenamel junc-
fracture of the maxillary right second molar. He
tion of the segment to the apical level was roughly 5
reported that pain on mastication in the tooth had
mm (Figure 4B).
persisted for approximately 1.5 months. From the
dental history, it was learned that the tooth had At the fourteen-day follow-up, the patient was
been treated by pulp mummification previously. The asymptomatic, and the soft tissues were healthy.
clinical examination showed that a previous filling The zinc oxide–eugenol cement was removed, a 1.1-
was absent, resulting in a large cavity of the mm titanium post (Anthogyr Company, Sallanches,
maxillary right second molar. Some discharge of France) was luted in the lingual canal, and a 0.75-
purulence was present in the lingual region of the mm stainless-steel post (Xihu Biomaterials Compa-
Figure 5. Case 5. (A) A fracture running buccolingually along the margin of the restoration on the mandibular left second molar (the arrow indicates
the fracture). (B) Preoperative radiograph. (C) Clinical appearance after the root canal treatment; the fractured segment was extracted. (D)
Radiograph was taken at 21 days after the remaining crown was temporarily restored with zinc oxide–eugenol cement. (E) Fractured distal segment.
(F) Occlusal view at the four-year follow-up after insertion of the crown. (G) Four-year radiographic follow-up.
ny, Hangzhou, China) was luted in the distobuccal reported that pain on mastication in the tooth had
canal (Figure 4C). A coronal restoration with persisted for approximately one month. From the
composite resin (Z250, 3M ESPE) was then placed dental history, it was learned that the tooth had
at the juxtagingival level. A full metal crown was been treated by pulp mummification previously. The
chosen to restore the tooth (Figure 4D). clinical examination showed a large occlusal-lingual
amalgam restoration on the mandibular left second
At the three-year, six-month follow-up, the tooth
molar and a fracture line running buccolingually
was free of clinical symptoms, was functioning
along the distal margin of the restoration, separating
normally, and had a healthy clinical appearance
the tooth into two distinct components (Figure 5A).
(Figure 4E). No pockets around the tooth were
The distal fragment was mobile in the lateral
detected. The radiographic examination revealed a
direction, and the tooth was nonresponsive to pulp
normal periodontal ligament of the tooth and no
vitality testing. No pockets around the tooth were
signs of periapical disease (Figure 4F).
detected. Periapical radiography revealed no signs of
periapical disease (Figure 5B). With the patient’s
Case 5 consent, local anesthesia was administered, the
A 68-year-old male patient presented with a crown mobile distal segment and the silver amalgam
fracture of the mandibular left second molar. He restoration were removed, and a one-visit root canal
treatment was performed (Figure 5C). The remain- procedures can be managed with strict moisture and
ing crown was temporarily restored with zinc oxide– bleeding control. The first clinical procedure involves
eugenol–based cement applied supragingivally (Fig- retrieving the fragment of the traumatized tooth.
ure 5D). No antibiotic was administered. The visual This step will indicate the level of fracture and
examination showed that the distal surface of the whether the pulp is involved. Only then should a
extracted segment comprised the cervical third of the treatment plan be determined.3
distal root, that the fracture of the root was oblique
An appropriate treatment plan after an injury is

in pattern, and that the longest distance from the important for a good prognosis. A tooth with a
cementoenamel junction of the segment to the apical complicated crown-root fracture presents many
level was roughly 5 mm (Figure 5E).
problems with regard to coronal restoration when
At the twenty one-day follow-up, the patient was the fracture line extends below the marginal bone
asymptomatic, and the soft tissues were healthy. level.9 The treatment of complicated crown-root
The zinc oxide–eugenol cement was removed, a 1.3- fractures in molars is dependent on the extent,
mm–thick glass fiber–composite post (Produits Den- duration, and location of the fractures. According to
tarires SA) was luted in the mesiobuccal canal and the recommendations of the International Associa-
mesiolingual canal individually, and a coronal tion of Dental Traumatology,10 various treatment
restoration with composite resin (Z250, 3M ESPE) approaches to complicated crown-root fractures
was then placed at the juxtagingival level. A full have been indicated: 1) fragment removal and
metal crown was chosen to restore the tooth. gingivectomy (sometimes ostectomy); 2) orthodontic
extrusion of apical fragments; 3) surgical extrusion
At the four-year follow-up, the tooth was free of

clinical symptoms, was functioning normally, and of apical fragments; 4) decoronation; and 5) extrac-
had a healthy clinical appearance (Figure 5F). No tion. However, reports on the treatment of crown-
pockets around the tooth were detected. The radio- root fractures of molars are limited in number.
graphic examination revealed complete bone healing Theodossopoulou6 described a case of a crown-root
around the distal marginal surface of the tooth and fracture of the mandibular first left molar in which
no signs of periapical disease (Figure 5G). the tooth was treated by combining orthodontic
extrusion and effective endodontic and prosthetic
DISCUSSION therapy.
In the present article, the teeth are pulpless, and Preservation of the gingival biologic width is
since the fractures involved the chamber, we critical for the long-term success of the treatment.5
grouped these fractures into the ‘complicated’ cate- We intentionally selected these cases to be reported
gory. The cause of these complicated crown-root because the extent of the injuries was nearly the
fractures in molars could be attributed to large-size same. We demonstrated that healing of the peri-
restorations without proper cuspal protection. A odontal tissues occurred in all of the cases, despite
conservative treatment was presented, by which the different locations of the fractures. The gingiva
the fragments were removed to allow for proper reattached to the exposed dentin after the loose
healing of the periodontal tissues, and root canal fragments were removed, and none of the teeth
treatments were performed; afterwards, the coronal exhibited signs of pathology at follow-up; in addition,
portion could be restored at the juxtagingival level. bone healing was observed around the incomplete
There was good marginal adaptation, and the simple root surface of the tooth (case 5). This study was
technique presented here seemed to be effective. The confirmed, and it is concluded that the indication for
advantages of this treatment method include the conservative treatment of complicated oblique
rapid and conservative nature of the treatment and crown-root fractures of molars may be greater than
the simplicity of the procedure; in addition, there are previously has been thought.
economic advantages as well as a greater likelihood There are many ways of managing crown-root
of cooperation from the patient. fractures of a molar, and the clinician may have
Crown-root fractures have immediate implications difficulties deciding on the appropriate treatment
for the endodontic, restorative, and periodontal option. In these cases, the patients wish to preserve
prognoses as a result of the line of fracture, which their own teeth. If complications occur with the
is subgingival. The treatment objective must be conservatively treated teeth, all other treatment
aimed at exposing the fracture margins, juxtagingi- options, such as a fixed partial denture or a dental
vally or supragingivally, so that all of the clinical implant, are still possible.
CONCLUSION 3. Olsburgh S, Jacoby T, & Krejci I (2002) Crown fractures

in the permanent dentition: Pulpal and restorative
These case studies demonstrate that molars with considerations Dental Traumatology 18(3) 103-115.
complicated crown-root fractures can be managed
4. Heithersay GS (1973) Combined endodontic-orthodontic
using an uncomplicated method, which can result in treatment of transverse root fracture in the region of the
satisfactory periodontal healing. alveolar crest Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology and Endodontology 36(3)
404-415.
Acknowledgement
This study was supported by the National Nature Science 5. Padbury A, Eber R, & Wang HL (2003) Interactions
Foundation of China (Grant 81070832). between the gingiva and the margin of restorations
Journal of Clinical Periodontology 30(5) 379-385.
Conflict of Interest 6. Theodossopoulou JN (1997) Crown-root fracture of lower
molar-restorative procedures Dental Traumatology 13(4)
The authors of this manuscript certify that they have no
proprietary, financial, or other personal interest of any nature 193-195.
or kind in any product, service, and/or company that is 7. Roeters J, & Bressers JP (2002) The combination of a
presented in this article. surgical and adhesive restorative approach to treat a deep
crown-root fracture: A case report Quintessence Interna-
(Accepted 14 December 2012) tional 33(3) 174-179.
REFERENCES 8. Grossman LI (1960) Pulp mummification In: Grossman LI
(ed) Endodontic Practice Lea & Feibiger, Philadelphia,
1. Andreasen JO, & Andreasen FM (1994) Crown-root 116-117.
fractures In: Andreasen JO, Andreasen FM (eds) Text-
book and Color Atlas of Traumatic Injuries to the Teeth 9. Caliskan MK, Turkun M, & Gomel M (1999) Surgical
Munksgaard, Copenhagen 257-341. extrusion of root-fractured teeth: A clinical review
International Endodontic Journal 32(2) 146-151.
2. Bakland LK, Andreasen FM, & Andreasen JO (2002)
Management of traumatized teeth In: Walton RE, 10. International Association of Dental Traumatology The
Torabinejad M (eds) Endodontics: Principle and Practice dental traumatol guide; Retrieved online September 4,
Saunders, St Louis, MO 445-465. 2012 from: http://www.iadt-dentaltrauma.org

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Operative Dentistry, 2013, 38-3, E67-E75

SUMMARY loss of tooth structure. After the mobile crown-

The treatment strategy for crown-root fractures is

oxide–eugenol–based cement applied supragingi-

Case 3 signs of periapical disease (Figure 3B). With the

An appropriate treatment plan after an injury is

At the four-year follow-up, the tooth was free of

CONCLUSION 3. Olsburgh S, Jacoby T, & Krejci I (2002) Crown fractures

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