Frontiers in Dentistry

Endodontic Management of Complicated Vertical Crown-Root

Fracture in Deciduous Molars: Report of Two Cases
Richa Kumari1, Neeraj Kumar2*, Krishan Gauba3
1. Unit of Paedodontics and Preventive Dentistry, Oral Health Sciences Centre, Post graduate Institute of Medical
Education and Research, Chandigarh, India
2. Department of Dentistry, Government Medical College, Khandwa, Madhya Pradesh, India
3. Unit of Paedodontics and Preventive Dentistry, Oral Health Sciences Centre, Post graduate Institute of Medical
Education and Research, Chandigarh, India

Article Info ABSTRACT

Article type: Dental traumatic injuries most commonly occur in the primary and mixed dentition,
Case Report but vertical complicated crown-root fractures are rarely seen in children. Clinical and
radiographic examination of these injuries helps in accurate diagnosis and
management. According to the International Association of Dental Traumatology
Article History:
guidelines, treatment usually involves extraction followed by placement of a space
Received: 29 Apr 2020
maintainer. Cases of complicated crown and root fracture in primary posterior teeth
Accepted: 13 Nov 2020
are often unnoticed by the clinician, at the time of injury. Two such patients are
Published: 28 Dec 2020
presented, who reported symptoms a few weeks after their accident. They were
* Corresponding author: managed conservatively by initial stabilization with stainless steel crowns, followed
Department of Dentistry, Government by root canal therapy. This report highlights the need for referral to specialists and
Medical College, Khandwa, Madhya emphasizes the importance of conservative management of primary teeth to
Pradesh, India maintain functional demands.
Key words: Crowns; Pulpectomy; Wounds and Injuries; Tooth Fractures; Tooth,
Email: [email protected]
Deciduous; Endodontics

 Cite this article as: Kumari R, Kumar N, Gauba K. Endodontic Management of Complicated Vertical Crown-Root
Fracture in Deciduous Molars: Report of Two Cases. Front Dent. 2020;17:39. doi: 10.18502/fid.v17i39.5292

INTRODUCTION The most common sources of traumatic injuries

Traumatic injuries to the oral cavity are to children includes falls, collisions, motor vehicle
considered as one of the most common dental accidents, contact sports, and malocclusions like
health issues in children younger than 6 years of increased over-jet and incompetent lips [5].
age. These injuries generally range from 11%- Crown-root fractures of primary molars are
30.2% in the primary dentition with a reported classified into ‘uncomplicated’ and
crown-root fracture prevalence of 2%-2.5% [1,2]. ‘complicated’ types, based on pulpal involve-
Their peak incidence occurs between the ages of ment. The treatment method most commonly
2-4 years in the primary dentition and the most reported for complicated crown-root fractures
common type is luxation injury, which develops of primary teeth is extraction of the tooth
because of the soft and pliable nature of the followed by placement of a space maintainer, as
alveolar bone in children [3]. Direct impact to the per the International Association of Dental
mouth particularly causes luxation of the primary Traumatology guidelines [6]. However, preser-
maxillary incisors. However, indirect impact such vation of the tooth should be the main
as trauma to the chin may result in perpendicular consideration, as primary teeth are essential
or obliquely directed forces, leading to crown- for maintaining growth of the alveolar bone,
root fractures [4]. arch length and mastication.

Copyright © 2020 The Authors. Published by Tehran University of Medical Sciences.

This work is published as an open access article distributed under the terms of the Creative Commons Attribution 4.0 License
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Vertical Crown-Root Fracture in Deciduous Molars

Fig. 1. Representative images of crown-root fracture management of Case 1. Preoperative intra oral view (1A)
and periapical radiograph (1B) of lower first and second primary molars, showing crown-root fracture.
Stainless steel crowns were placed followed by pulpectomy (1C,1D). Twelve-month (1E), 24-month (1F) and
36-month (1G,1H) follow-up were uneventful

The cases presented herein, demonstrate the We decided to preserve the primary teeth and
conservative management of complicated after explanation to the parents, consent was
crown-root fractures of deciduous molars obtained. Stabilization of the fractured
which were stabilized by stainless steel segments was done with flowable composite
crowns, followed by endodontic treatment (Filtek Z350 XT, 3M, ESPE, USA) followed by
and resin restoration. These cases were crown preparation, placement of stainless
clinically and radiographically followed for 36 steel crowns (3M, ESPE, USA) and
months without any complications. cementation, using GIC luting cement. Under
rubber dam isolation, access was gained
CASE REPORT through the crown followed by biomechanical
A 5-year-old girl reported to the unit of preparation, obturation with metapex
Pediatric Dentistry with a chief complaint of (Metapex Biomed Co. Ltd, South Korea),
‘pain in her left lower back teeth’, during restoration with GIC (Fuji II) and composite
chewing. There was a history of trauma from (3M, ESPE, USA) (Figures 1C and 1D). The
falling off a swing, 4 months back. Her chin had child was instructed to maintain oral hygiene
struck directly against the ground, leading to a and all other carious teeth were restored
deep laceration which was immediately during the subsequent appointments. On the
sutured by a private practitioner. The patient recall visits on months 12 and 24 (Figures 1E
did not exhibit dental pain at that time. After 4 and 1F), there was no clinical or radiographic
months, she started experiencing pain in her pathology, with physiologic root resorption.
left lower posterior teeth while eating. Medical The patient was asymptomatic clinically and
history revealed no systemic illness or history radio-graphically after 36 months and showed
of previous hospitalization. On examination continuation of physiologic root resorption
there was evidence of a healed laceration on (Figures 1G and 1H).
the chin with no facial asymmetry and mouth Case 2
opening was normal. Intraoral examination A 5-year-old girl reported to our department
revealed a complicated crown-root fracture of with a chief complaint of ‘pain in her upper left
the left first and second primary mandibular back tooth’ while eating. The patient’s father
molars, which was confirmed by a periapical gave a history of falling from a height of 5 feet
radiograph (Figures 1A and 1B). while playing.

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 Kumari R, et al.

Fig. 2. Treatment of crown-root fracture in Case 2. Preoperative intraoral photograph (2A) and periapical
radiograph (2B) show crown-root fracture in the upper left second primary molar. A stainless steel crown was
placed, after which pulpectomy was performed (2C, 2D). No failure was observed in the 12-month (2E), 24-
months (2F) and 36-months (2G, 2H) follow-up

She suffered abrasive injuries on the right side forces caused by a blow to the chin region, are
of her face, chin and neck, which were treated extremely rare. Holan et al [7] reported that
in a private hospital. No active intervention 32%-35% of direct injuries to the mental area
had been done for dental pain. The patient may result in coronal fractures of primary
reported to the department 10 days after the molars. In both presented cases, the children
day of injury. Medical history was not were approximately 5 years old, which
contributory. Extraoral examination revealed corresponds to the peak age-range of traumatic
healed abrasive injuries on the right side of the dental injuries. The fact that the etiology in both
forehead, cheek, chin and neck. Intraoral patients was falling while playing, also
examination showed a crown fracture coincides with the most frequent cause of
extending from the cervical region to the dental traumatic injuries in children [1,2].
occlusal surface of the left maxillary second In most instances, crown-root fractures
primary molar with subgingival extension of remain undetected immediately after trauma,
the fracture line (Figures 2A and 2B). There but they may be manifested a few
was no periapical abscess or fistula. Because of days/months later when the patient starts
the patient’s age, conservative treatment was experiencing pain/gingival inflammation [8].
opted similar to that discussed in Case 1, i.e., In both presented cases, primary teeth were
stabilization with stainless steel crown fractured because of a sudden blow to the chin,
followed by endodontic therapy of the which dissipated forces indirectly to the
offending tooth (Figures 2C and 2D). The child posterior primary teeth. Limited cases exist in
was followed for 12, 24 (Figures 2E and 2F) the literature where more than two teeth had
and 36 months with no clinical/radiographic been fractured. According to a previous study,
signs of failure (Figures 2G and 2H). only two out of 96 children had five fractured
primary molars, while 20.3% of the children
DISCUSSION had one tooth fractured due to trauma to the
Crown-root fractures resulting from indirect chin region [7].

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Vertical Crown-Root Fracture in Deciduous Molars

Management of simple and complicated crown CONCLUSION

fractures in primary teeth varies from simple This case report emphasizes the importance of
grinding of sharp cusps to pulp capping, general physicians/dentists referring cases
pulpotomy, pulpectomy, restoration with with chin injuries to pedodontists. It also
adhesive resins or stainless steel crowns, and highlights the need for conservative
extracting the offending tooth followed by use management of fractured primary teeth so
of a space maintainer. Most authors have that their function could be maintained and
opted for radical treatment of fractured teeth the clinical problems that may arise after
in the form of extraction and space extraction can be better managed.
maintenance [9]. Examples include Morisaki
et al [10], who selected this treatment to ACKNOWLEDGMENTS
manage a crown-root fracture of a lower left The authors want to acknowledge that the
first primary molar in a 21-month-old boy and present case was managed at Post graduate
others [11,12] that reported four complicated Institute of Medical Education and research,
crown-root fractured primary molars, which Chandigarh. The details related to the present
were extracted because of pulp involvement case were not copied from any other sources.
and extensive damage. The authors have no conflict of interest.
Limited case reports exist where vertical
complicated crown fractures are managed CONFLICT OF INTEREST STATEMENT
conservatively with follow-up ranging from 0- None declared.
15 months. It is noteworthy that following
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