Bharti K et al.

: Complicated vertical crown – root fracture in permanent molar

CASE REPORT

The Management of Complicated Vertical

Crown – Root Fracture in Permanent Molar:
A Case Report with Review of Literature
Bharti Kusum1, Khurana Heena2, Pandey Ramesh Kumar3
1- M.D.S., Senior Resident, Department of Pedodontics and Preventive Dentistry, Maulana Correspondence to:
Dr. Bharti Kusum, Senior Resident, Department of
Azad Institute of Dental Sciences, MAMC Complex, BSZ marg, New Delhi-110002, India. 2-
Pedodontics and Preventive Dentistry, Maulana Azad
M.D.S., Senior Lecturer, Department of Pedodontics and Preventive Dentistry, GIDSR, Institute of Dental Sciences, MAMC Complex, BSZ marg,
Ferozpur, Punjab. 3- M.D.S., Professor, Department of Pediatric and Preventive Dentistry, New Delhi-110002, India.
Faculty of Dental Sciences, King George’s Medical University, Chowk, Lucknow. Contact Us: www.ijohmr.com

ABSTRACT
The present case report represents a conservative management of a complicated crown – root fracture along with
vertical fracture in permanent mandibular left molar due to blowing on under surface of chin. Clinically fractured
mesiobuccal cusp was mobile but attached to the gingival fibres and on removal the cusp was stored frozen until
bonding. Access opening revealed another fracture running vertically between the buccal and lingual cusps. Endodontic
treatment was performed as there was no bleeding through the canals. The vertical fracture was sealed using dual cure
resin intraorally and afterwards the fractured cusp was reattached. Access opening was restored with composite
restoration followed by stainless steel crown. The present case report demonstrates that such a conservative treatment
approach is a reliable and predictable method to save a tooth that would have otherwise been difficult to restore.
KEYWORDS: Crown-Root Fracture, Vertical Fracture, Dual Cure Resin

s
INTRODUCTION
The crown –root fractures comprises 5% of injuries
affecting the permanent dentition and 2% in the primary
dentition.1 Crown –root fractures in the anterior region
are usually caused by direct trauma while in posterior
region by indirect trauma. The complicated crown – root
fracture running vertically along long axis and deviating
in a mesial or distal direction in molar is a rare type of
dental injury.2 Clinically, in crown-root fractures, the
coronal fragments are usually only slightly displaced and
being kept in position by fibers of the periodontal
ligament orally and /or the dental pulp. Radiographic
findings seldom contributed to the clinical diagnosis, as
the oblique fracture line is almost perpendicular to the
central beam. The vertical fractures running in facio-oral
plane are easily determined radiographically while in a
mesio-distal direction are seldom seen. The
communication with the oral cavity to the pulp and
periodontal ligament in these fractures permits bacterial
invasion and subsequent inflammation. So, fracture
healing cannot be expected in crown-root fractures, in
contrast to root fractures where the fracture is located
entirely within the alveolus. Vertical fracture can be
‘complete tooth fracture’, where there is a visible
separation at the interface of segments along the line of
fracture or the segments can be easily separated or
‘incomplete tooth fracture’ where there is fracture plane
of unknown depth and direction passing through the tooth
How to cite this article:
Kusum B, Heena K, Pandey RK. The Management of Complicated Vertical Crown – Root Fracture in Permanent Molar: A Case Report with Review of Literature. Int J Ora
structure that, if not already involving, may progress to
communicate with the pulp and/or periodontal ligament.3,4
Vertical root fracture in a multi-rooted tooth can be
conserved by resection of the root, however, a vertical
fracture in a single-rooted tooth usually has a hopeless
prognosis and results in extraction.5-7 This clinical report
describes the conservative management of a vertically
running complicated crown–root fracture of a permanent
mandibular left first molar.
CASE REPORT
A 11-year-old child reported to the Department of
Pedodontics, King George’s Medical University, U.P,
Lucknow (India) with pain on chewing on both sides of
dental arch. The parent narrated history of traumatic
injury to the mandible, in an upwards direction 15 days
back. Clinical examination revealed a healing lesion over
the chin area with no other extraoral finding (Fig. 1).
Complete palpation, percussion and biting test were
performed for all the teeth in the oral cavity. Intraoral
examination revealed fractured cusps of permanent
mandibular right and left first molars (Fig.2&3
respectively) and primary mandibular right second molar
(Fig. 4). Full mouth intraoral periapical (IOPA)
radiographs were recorded, and the above mentioned
fractures were observed (Fig. 5,6).

International Journal of Oral Health and Medical Research | ISSN 2395-7387 | NOVEMBER-DECEMBER 2015 | VOL 2 1
 Bharti K et al.: Complicated vertical crown – root fracture in permanent
Fig 1. Healing scar over the undersurface of chin.
Fig 2.Photographs showing fractured cusps of permanent
mandibular right first molar
Fig 3. Photographs showing fractured cusps of permanent
mandibular left first molar
Fig 4. Photographs showing fractured cusps of primary
mandibular right second molar respectively
International Journal of Oral Health and Medical Research | ISSN 2395-7387 | NOVEMBER-DECEMBER 2015 | VOL 2
CASE REPORT
Fig 5. Preoperative radiograph showing fracture lines in permanent
mandibular right first molar & primary mandibular right second molar
Fig 6. Preoperative radiograph showing fracture lines in permanent
mandibular left first molar
Management of permanent mandibular left first
molar: Clinically fractured mesiobuccal cusp was mobile
but attached to the gingival fibres and on separation pulp
tissue was exposed (Fig. 7). As it was found to be a
complicated crown-root fracture endodontic therapy was
planned as the history of trauma was 15 days back
followed by fragment reattachment and crown placement.
The fractured cusp was stored frozen until bonding (Fig.
8). The access opening revealed another fracture line
running between the buccal and lingual cusps mesio-
distally (Fig. 9). It was considered incomplete fracture as
its apical extent could not be ascertained. IOPA depicted
three rooted molar, and incomplete fracture line(IFL) was
not clear due to its mesio-distal extension(Fig. 6). The
coronal portion was already weak due to fractured
mesiobuccal cusp and access opening , so, extraoral
sealing of the IFL after extraction was not considered.
Hence it was decided to seal the fracture line intraorally
without extracting the tooth according to procedure been
described by Sugaya et al. Endodontic treatment was
performed as there was no bleeding from the canals. 8 The
pulp chamber was cleaned, dried and fracture line was
made apart (Fig. 10). Afterwards dual cure resin (Smart
Cem 2, Dentsply, Milford) was placed in that gap, and the
two fractured segments were held in contact with the
forceps for the required setting time in order to prevent
separation (Fig. 11). The fractured mesio-buccal cusp was
reattached using dual cure resin followed by sealing off
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 Bharti K et al.: Complicated vertical crown – root fracture in permanent CASE REPORT

Fig 7. Photograph showing exposed pulp tissue of permanent

Fig 11. Flowed dual cure resin over the fracture line
mandibular left first molar.
access cavity by composite resin (Fig. 12). Tooth was
capped using stainless steel crown to reinforce the
fractured tooth (Fig. 13-15). The root surface was
debrided by hand and ultrasonic scaler for removal of
extra resin along root surface. Patient was recalled after
one week followed by three months and nine months
revisit (Fig. 16).
Management of permanent mandibular right first
molar: Since clinical examination revealed
uncomplicated crown-root fracture of the mesiolingual
cusp (Fig. 17). The fractured cusp was reattached using

Fig 8. Removed mesiobuccal cusp of permanent mandibular left

first molar.

Fig 9. Photograph depicting another fracture line running mesio-distally

Fig 12. Completed post obturation filling.

Fig 10. Fracture line separated

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 Bharti K et al.: Complicated vertical crown – root fracture in permanent CASE REPORT

Fig 13. Occlusal reduction for crown placement depicting

flowed resin over the fracture line

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 Bharti K et al.: Complicated vertical crown – root fracture in permanent
Fig 14. Completed restorations over the permanent mandibular right and
left first molar.
Fig 15. Post operative radiograph of permanent mandibular left first
molar.
Fig 16. Follow up photograph after 9 months showing normally erupting
mandibular right second premolar.
Fig 17. Photograph after removal of fractured cusp of permanent
mandibular right first molar.
International Journal of Oral Health and Medical Research | ISSN 2395-7387 | NOVEMBER-DECEMBER 2015 | VOL 2
CASE REPORT
dual cure resin (Fig. 18) followed by stainless steel crown
to reinforce the fractured tooth (Fig. 14,19).
Management of primary mandibular right second
molar:
The clinical examination revealed complicated crown-
root fracture (Fig. 4) and resorbed roots radiographically
(Fig. 5). The tooth was extracted and follow up was done
to observe the normal eruption of the mandibular right
second premolar (Fig. 16).
Fig 18. Photograph after fragment reattachment of permanent
mandibular right first molar.
Fig 19. Post operative radiograph of permanent mandibular right first
molar.
The vertically running complicated crown-root fractures
in DISCUSSION
posterior teeth have the poorest prognosis. So, an
attempt was made to save the tooth by taking the idea
from the previous studies. Different approaches have
been attempted to treat the vertical root fractures. Oliet
extracted three vertically fractured teeth, cemented the
segments with cyanoacrylate extra-orally and replanted
them. Three months later, one of the teeth was extracted
being refractured.9 Fifteen months later, two of the teeth
were still comfortable and functional, but the long-term
prognosis was accessed poor. Trope & Rosenberg
extracted a vertically fractured maxillary second molar,
bonded the two segments with glass-ionomer bone
cement and replanted the molar in conjunction with an e-
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 Bharti K et al.: Complicated vertical crown – root fracture in permanent
PTFE (expanded polytetrafluoroethylene) membrane.10
After 1 year, the tooth remained functional. Selden
reported a two-stage surgical procedure that incorporated
bonding with silver glass-ionomer cement, placement of a
bone graft material, and guided tissue regeneration
therapy.11 Five out of six roots failed within 2–11 months.
Masaka bonded the fractured segments of six teeth using
4-META/MMA-TBB (4- acryloyloxyethyl trimellitate
anhydride/methyl methacrylate-tri-n-butylborane) resin
through the root canals.12 Five out of 6 roots were
functional for more than 10 years. Twenty-eight roots
were extracted and bonded extra-orally and replanted.
Twenty-four roots (out of 28) were functional or 5 years.
Hayashi et al. evaluated the short- and long-term
prognosis of replanted teeth with vertical root fractures
bonded with resin cement.13,14 The authors evaluated 8
incisors, 14 premolars and 4 molars for 4–76 months and
reported no extraction because of failure of incisors and,
therefore, described this method as a predictable
treatment for incisors but not for premolar or molar teeth .
Sugaya et al. evaluated the periodontal healing after
bonding treatment of vertical root fracture and divided
fractured teeth into two groups: group A: intra-orally
bonded, and group B: extra-orally bonded. In group A,
the fractured root was bonded through the root canal
without tooth extraction. Following root canal
preparation, the canal was filled with 4- META/MMA-
TBB resin and the cast-post inserted. The fractured
segments were held in contact with the forceps for the
required setting time in order to prevent separation. 8 In
the present case, extraction was not possible due to
already weakened coronal tooth structure (fractured
mesiobuccal cusp and access opened tooth).So, intraoral
approach for bonding was chosen in the present case as
evidenced by Sugaya et al.8 The reattachment of fractured
fragments offer several advantages i.e. improved esthetics
and function, potential durability in terms of surface
anatomy and wear, conservation of sound remaining
tooth tissue over conventional methods of treating and
restoring fractured teeth.15 Reattachment using resin has
been used earlier both in the anterior and posterior
teeth.16-19 In the present case, reattachment was done
using dual cure resin, Smart Cem 2 containing Urethane
Dimethacrylate, di and tri- Methacrylate resins and
fluorides. Additionally, occlusal composite resin placed
for the restoration of the endodontic access cavity has
certainly provided inner reinforcement to the reattached
fragment.9 External reinforcement of the fracture using
the stainless steel crown has been used for the first time
in the present case report.
CONCLUSION
The present case report demonstrates that a conservative
treatment approach to a vertically extended complicated
crown-root fracture is a reliable and predictable method
to save a tooth that would have otherwise been difficult to
International Journal of Oral Health and Medical Research | ISSN 2395-7387 | NOVEMBER-DECEMBER 2015 | VOL 2
CASE REPORT
restore with a resultant good long-term prognosis. Hence
vertically fractured tooth may be saved and restored with
functional and aesthetically pleasing result but further
long term follow up is necessary to evaluate reliability of
this technique.
1. Andreasen JO. Etiology and pathogenesis of traumatic
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