Esthetic and Endodontic Management of A Deep Crown-Root Fracture of A Maxillary Central Incisor

359
Journal of Oral Science, Vol. 54, No. 4, 359-362, 2012
Case Report
Esthetic and endodontic management of a deep crown-root

fracture of a maxillary central incisor
Tamotsu Tsurumachi1,2), Sakurako Matsumoto1), Yoshimi Kobayashi1),
Kinuyo Ohara1), Yusuke Suzuki1) and Bunnai Ogiso1,2)
2)Division
1)Department
of Endodontics, Nihon University School of Dentistry, Tokyo, Japan

of Advanced Dental Treatment, Dental Research Center, Nihon University School of Dentistry,
Tokyo, Japan
(Received 27 July and accepted 6 October 2012)
Abstract: Treatment of trauma to anterior teeth

should aim at preserving the affected teeth so as to
restore function and esthetic appearance. Recently,
patients have come to expect adequate esthetics
immediately after trauma. In the present case, a
deep crownroot fracture compromised the pulp
and extended subgingivally on the palatal aspect.
After using the fractured fragment as a provisional
crown, the patient received conventional root canal
treatment, which provided immediately satisfactory
esthetic results and reliable short-term restoration of
the crown-root fractured tooth. Rehabilitation of the
fractured central incisor was performed with a postcore-supported prosthetic restoration. (J Oral Sci 54,
359-362, 2012)
Keywords: crown-root fracture; esthetic treatment;
original fragment; provisional crown; root
canal treatment.
Introduction
Traumatic dental injuries cause damage ranging from

minimal enamel loss to complex fractures involving pulp
tissue. Treatment of fractured teeth depends on the level
of the fracture line and the amount of remaining tooth
Correspondence to Dr. Tamotsu Tsurumachi, Department of
Endodontics, Nihon University School of Dentistry, 1-8-13
Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8310, Japan
Tel: +81-3-3219-8142
Fax: +81-3-3219-8348
E-mail: [email protected]
(1). Conventional approaches to rehabilitating fractured

anterior teeth include composite restorations (2) and
post-core-supported prosthetic restorations (3). Recently,
it has become possible to use reattachment technique to
preserve the fractured segment of a tooth, which offers
better short- (4) and medium-term (5) results as compared
with resin composite restorations.
Crown-root fractures extend below the cementoenamel junction and require a multidisciplinary treatment
approach (5). If pulpal exposure is extensive in permanent anterior teeth with complete root development, the
fractured segment is usually removed and post-core and
crown restoration is done after root canal therapy (6).
Furthermore, patients often wish to recover their smile as
soon as possible and maintain it throughout subsequent
treatment (7).
The fracture fragment has been proposed as a favorable
crown repair material due to its superior morphology,
conservation of structure, and patient acceptance (8).
In addition, use of such fragments can create an environment conducive to periodontal healing. The present
report describes a case of immediate esthetic resolution
by using a fractured crown fragment and endodontic
treatment of a deep crown-root fracture of a central
incisor, which resulted in periodontal health. Rehabilitation of the fractured central incisor was accomplished by
post-core-supported prosthetic restoration.
Case Report
A 58-year-old man was referred to the Endodontic

Department at Nihon University School of Dentistry
for evaluation and treatment of his maxillary left central
360
Fig. 1 P
reoperative clinical view; note
lip laceration and swelling.
Fig. 2 Preoperative radiograph showing

two horizontal fracture lines.
Fig. 3 Clinical view immediately after

removal of fractured crown.
Fig. 4 P
alatal view showing subgingival fracture site of maxillary
left central incisor.
Fig. 5 Provisional crown showing the

fractured crown and screw-post.
Fig. 6 P
alatal view of maxillary left
central incisor after root canal
filling.
Fig. 7 Radiograph immediately after

obturation of root canal.
incisor (tooth 21), which had been fractured during a fall

from his bicycle on the previous day. At his first visit,
he had undergone emergency treatment for soft-tissue
wounds at the Department of Oral Surgery. The patients
medical history was noncontributory.
Extraoral investigation revealed heavy swelling of
the upper lip and slight swelling of the lower lip (Fig.
1). No further damage to extraoral tissues was seen. No
pathologic findings were noted during investigation of
the temporomandibular joint and potentially affected
osseous structures.
Intraoral investigation revealed that the maxillary
left central incisor had a crown-root fracture extending
subgingivally on the palatal aspect. The tooth fragment was mobile but remained in place. Radiographic
examination showed clear horizontal fracture lines at
both proximal sites (Fig. 2). The neighboring teeth had
Fig. 8 Radiograph after placing provisional crown on tooth.
no clinical or radiographic evidence of damage due to

trauma. A clinical diagnosis of irreversible pulpitis
was established. After administering local anesthesia,
the horizontally fractured crown was separated from
the remaining tooth (Fig. 3), and the fractured crown
was preserved in physiologic saline solution. After
extracting the coronal fragment, the fracture extending
subgingivally on the palatal aspect was noticeable (Fig.
4). Pulpal exposure was seen on the palatal aspect of
the tooth, close to the gingival margin. A #4 round bur
was used with 2.6% sodium hypochlorite irrigation to
prepare an approximately 3-mm-deep access cavity into
the pulp. The area was rinsed with saline solution until
pulpal hemorrhage was controlled. Temporary filling was
then used to fill the cavity, and the tooth was treatment
planned for conventional root canal therapy.
After 3 days, the tooth 12 was anesthetized and extir-
361
Fig. 9 L
abial view of provisional crown,
showing excellent adaptation between
the crown fragment and tooth.
Fig. 10 Lingual view of provisional

crown.
Fig. 11 S
ix-month follow-up radiograph
of maxillary central incisor.
Fig. 12 Postoperative clinical view 1

year after trauma.
Fig. 13 Fourteen-month follow-up radiograph of maxillary central

incisor.
Fig. 14 Postoperative labial view 1

year after insertion of permanent porcelain crown.
Fig. 15 Postoperative lingual view 1

year after insertion of permanent porcelain crown.
pated with the use of a Hedstrom file (Mani Inc, Tochigi,

Japan). A working length was established using an apex
locator (APIT 7, Osada Co, Tokyo, Japan) and radiography. The root canal system was thoroughly debrided
and prepared by step-back technique to an ISO size 40
master apical file. Copious irrigation with 2.6% sodium
hypochlorite solution was used throughout the procedure. At the same time, electrosurgery was performed
to re-establish the gingival margin and convert the
subgingival fracture site to a supragingival one. During
endodontic treatment, a provisional crown was fabricated
using a screw-post (Dentatus, New York, NY, USA) and
the natural fractured crown (Fig. 5). A hole was made in
the coronal fragment to receive the head of the screw-post.
After etching the coronal fragment with 37% phosphoric
acid gel for 20 s, dentine adhesive was applied according

to the manufacturers instructions and the hole was filled
with a composite resin placed over the screw-post. Then,
the provisional crown was fitted against the fractured
surface. Excess material was removed, and the resin was
light-cured for 40 s buccally and lingually.
Two weeks later, the root was symptom-free and was
obturated with gutta-percha and zinc oxide-eugenol
sealer (Canals, Showa Yakuhin, Tokyo, Japan), using
the lateral condensation method (Fig. 6). A postoperative
radiograph was obtained (Fig. 7), and the provisional
crown was then accurately placed on the remaining
root (Figs. 8-10). Occlusion was carefully checked and
adjusted. Four months later, the root was prepared for a
cast palladium post and core, and the porcelain crown
was cemented with glass-ionomer cement (Fuji Lute,
GC, Tokyo, Japan). The patient returned for periodic
checkups, which confirmed satisfactory healing (Figs. 11
and 12). At a follow-up examination at 14 months, he
was asymptomatic and his periodontal health was good
(Figs. 13-15).
Discussion
Achieving and maintaining satisfactory treatment

results for a traumatically fractured incisor is challenging for clinicians. Esthetic and functional outcomes
362
must be considered when determining the proper treatment method. Treatment modalities for crown-root
fractured teeth can change depending on the level of
the fracture line and the amount of remaining root (1).
In cases where the fracture line extends along the long
axis of the root, extraction of the tooth is indicated. If
the fracture involves the coronal third of the root, and
the remaining root structure is long enough to support
the subsequently applied restoration, only the fractured
portion is extracted and root canal therapy is performed
for prosthetic restorations (3). In cases of subgingival
fracture, gingivectomy and surgical or orthodontic extrusion of the root is necessary to convert the subgingival
fracture to a supragingival one, to allow restoration of the
fracture with prosthetic restorations (9). In the present
case, there was no need for additional extrusion of the
tooth because subgingival involvement of the fracture
site was present only at the palatal aspect of the tooth.
In maxillary incisors, crownroot fractures have a characteristic fracture line: on the facial side, the fracture is
localized paragingivally or supragingivally, while palatally the defect often extends far into the root region (6).
At the palatal site, gingivectomy with electrosurgery was
straightforward. This procedure allowed the fracture line
to be moved supragingivally, which optimized marginal
sealing (9). The main advantage of using electrosurgery
for gingivectomy is hemorrhage control, which can be
easily established soon after injury (10).
If pulpal exposure is extensive in permanent anterior
teeth with complete root development, the fractured
segment is usually removed and a post-core and crown
restoration is done after root canal therapy (6). In the
present case, we selected a provisional crown using a
fracture fragment to restore the fractured tooth. To our
knowledge, this is the first case in which a provisional
crown was fabricated using a screw-post and natural
fractured crown. The patient was very happy with this
procedure because the initial damage to his dentition
could be repaired soon after the accident. Use of an original tooth fragment instead of a provisional resin crown
before performing permanent fixed prostheses has many
advantages: shade, morphology, translucency, patient
acceptance, conservation of structure, and lower cost (8).
During this period, adequate root canal system cleaning,
shaping, and filling procedures are performed to ensure
successful endodontic treatment outcomes. In addition, a
healing period of 4 months is needed for recovery of the
periodontium, which can be affected by dental trauma.
Esthetics, function, and patient expectations must be
considered when selecting treatment. In this case, the
patient desired nonsurgical treatment and to retain the

tooth with a permanent esthetic porcelain crown.
The present case illustrates immediate esthetic and
functional rehabilitation of a fractured tooth, leading to
conservation and permanent restoration of the tooth.
Acknowledgments
This study was supported by a grant from the Sato

Fund, Nihon University School of Dentistry (2011).
References
1.
Olsburgh S, Jacoby T, Krejci I (2002) Crown
fractures in the permanent dentition: pulpal and
restorative considerations. Dent Traumatol 18,
103-115.
2.
Burke FJT (1991) Reattachment of a fractured
central incisor tooth fragment. Br Dent J 170,
223-225.
3. Fernandes AS, Dessai GS (2001) Factors affecting
the fracture resistance of post-core reconstructed
teeth: a review. Int J Prosthodont 14, 355-363.
4. Badami V, Reddy SK (2011) Treatment of complicated crown-root fracture in a single visit by means
of rebonding. J Am Dent Assoc 142, 646-650.
5. z IA, Hayta MC, Torolu MS (2006) Multidisciplinary approach to the rehabilitation of a
crown-root fracture with original fragment for
immediate esthetics: a case report with 4-year
follow-up. Dent Traumatol 22, 48-52.
6. Andreasen JO, Andreasen FM, Tsukiboshi T (2007)
Crown-root fractures. In: Textbook and color atlas
of traumatic injuries to the teeth, 4th ed, Andreasen
JO, Andreasen FM, Andersson L eds, Blackwell,
Oxford, 314-336.
7. Roeters J, Bressers JP (2002) The combination of a
surgical and adhesive restorative approach to treat
a deep crown-root fracture: a case report. Quintessence Int 33, 174-179.
8. de Castro JCM, Poi WR, Pedrini D, Tiveron ARF,
Brandini DA, de Castro MAM (2011) Multidisciplinary approach for the treatment of a complicated
crown-root fracture in a young patient: a case
report. Quintescence Int 42, 729-735.
9. Krastl G, Filippi A, Zitzmann NU, Walter C, Weiger
R (2011) Current aspects of restoring traumatically
fractured teeth. Eur J Esthet Dent 6, 124-141.
10. DiAngelis AJ, Jungbluth MA (1987) Restoration
of an amputated crown by the acid-etch technique.
Quintescence Int 18, 829-833.

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359

Journal of Oral Science, Vol. 54, No. 4, 359-362, 2012

Esthetic and endodontic management of a deep crown-root

of Endodontics, Nihon University School of Dentistry, Tokyo, Japan

Abstract: Treatment of trauma to anterior teeth

Traumatic dental injuries cause damage ranging from

(1). Conventional approaches to rehabilitating fractured

A 58-year-old man was referred to the Endodontic

Fig. 2 Preoperative radiograph showing

Fig. 3 Clinical view immediately after

Fig. 5 Provisional crown showing the

Fig. 7 Radiograph immediately after

incisor (tooth 21), which had been fractured during a fall

Fig. 8 Radiograph after placing provisional crown on tooth.

no clinical or radiographic evidence of damage due to

Fig. 10 Lingual view of provisional

Fig. 12 Postoperative clinical view 1

Fig. 13 Fourteen-month follow-up radiograph of maxillary central

Fig. 14 Postoperative labial view 1

Fig. 15 Postoperative lingual view 1

pated with the use of a Hedstrom file (Mani Inc, Tochigi,

acid gel for 20 s, dentine adhesive was applied according

Achieving and maintaining satisfactory treatment

patient desired nonsurgical treatment and to retain the

This study was supported by a grant from the Sato

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Fig. 2 Preoperative radiograph showing

Fig. 3 Clinical view immediately after

Fig. 5 Provisional crown showing the

Fig. 7 Radiograph immediately after

Fig. 8 Radiograph after placing provisional crown on tooth.

Fig. 10 Lingual view of provisional

Fig. 12 Postoperative clinical view 1

Fig. 13 Fourteen-month follow-up radiograph of maxillary central

Fig. 14 Postoperative labial view 1

Fig. 15 Postoperative lingual view 1