Management of Vertically Fractured Maxillary Second
Molar Volume 1 Issue 2
September 2010
45 Journal of Dental Sciences and Research
Case Report
Management of Vertically Fractured Maxillary Second
Molar
Dr. Jyothi K.N.
Professor and H.O.D., Department of Conservative Dentistry and, Endodontics, Sri
Siddhartha Dental College, Agalakote, Tumkur, Karnataka.
Abstract:
Vertical tooth fractures are longitudinal fractures of crown and /or root
which are caused by trauma, heavy occlusal forces and dental procedures.
There is little research on longitudinal tooth fractures related to diagnosis
and treatment out come. There are few reports where fractured tooth can be
salvaged intact and fully healthy when repositioned early and stabilized. This
case report explains the management of vertically fractured maxillary
second molar by intra coronal splinting and full coverage restoration.
Key Words: Vertical tooth fracture, Intracoronal splinting, Adhesive
technique, Full coverage restoration.
Journal of Dental Sciences & Research 1:2: Pages 45-50
Introduction:
Cracked teeth and their
related entities, as well as vertical
root fractures are longitudinal
fractures of the crown and / root.
These fractures occur in all tooth
groups and are caused by occlusal
forces and dental procedures.
There is relatively little research on
longitudinal tooth fractures,
particularly on clinical outcome
related to diagnosis and treatment.
Most treatment modalities are
based on opinion and anecdotal
information1.
When a vertical tooth
fracture extends below the gingival
attachment the recommended
treatment has been extraction. As
asserted by Walton after the
Management of Vertically Fractured Maxillary Second
Molar Volume 1 Issue 2
September 2010
46 Journal of Dental Sciences and Research
diagnosis of a split tooth is
confirmed saving the tooth is not
an option. But the literature also
reveals long term case studies by
David A Hall upto 20 years where a
fractured tooth can be completely
salvaged, intact and fully healthy
when repositioned early and
stabilized. The healing was
observed by cementum
deposition2.
Masaka in 1980 and Aouate
developed a technique for
preserving vertical root fractures
using 4 META adhesive extra orally
and then with replantation. But
they do not address the issue of
potential biological cementum
repair3.
The present case report
explains the management of
vertical fracture in maxillary
second molar by intracoronal
splinting using advanced adhesive
technique followed by a full
coverage restoration.
Case Report:
A female patient aged 35
years was referred to the
department of conservative
dentistry and Endodontics from
out-patient department Sri
Siddhartha Dental college, Tumkur.
Patient c/o pain on chewing in the
right posterior tooth region. She
gave h/o trauma one month ago
due to fall and was hurt on the
chin. On examination there was
vertical fracture of tooth 17, the
fracture line running mesio distally
splitting the tooth into 2 halves.
The fragments were intact and
were in position without any
displacement, but could be
separated by wedging with a
probe. The fracture line had
extended subgingivally involving
the furcation and passing through
the pulp chamber. There was no
sign of periodontal pocket. The
tooth was tender on percussion. It
was diagnosed as complicated
crown-root fracture of 17 (split
tooth). The sequence of treatment
planned was – splinting the tooth
with orthodontic band, root canal
treatment, intra coronal splinting of
fragments with self etching
Management of Vertically Fractured Maxillary Second
Molar
47 Journal of Dental Sciences and Research
adhesive and composite resin,
crown preparation followed by
cementation of metal crown.
Immediately after the examination
& diagnosis of vertical tooth
fracture in relation to 17 pa
was referred to orthodon
department for cementation
orthodontic band to hold the
fragments in position (fig.1&2)
Fig1:Fractured Maxillary Second
Splinted with Orthodontic Band
Fig 2: Pre-Operative radiograph
In the next appointment
root canal opening was done
fracture line was clearly seen
running mesiodistally involving
both the marginal ridges and
f Vertically Fractured Maxillary Second Volume 1 Issue 2
September 2010
Journal of Dental Sciences and Research
adhesive and composite resin,
crown preparation followed by
cementation of metal crown.
Immediately after the examination
of vertical tooth
fracture in relation to 17 patient
ed to orthodontia
department for cementation of
hold the
(fig.1&2)
Maxillary Second Molar
with Orthodontic Band
Operative radiograph
In the next appointment
root canal opening was done. The
fracture line was clearly seen
running mesiodistally involving
both the marginal ridges and
through the pulp chamber and the
palatal canal( fig.3). The root canal
treatment was completed and
temporary restoration was given.
Fig3:Fractured line running mesiodistally
shown under magnification
In the subseq
appointment temporary
was removed, access cavity was
thoroughly debrided with saline
and dried. Self etching adhesive
(Multilink) was applied to the
cavity according to manufacturer’s
instructions and the cavity was
restored with packable light cured
composite resin (Tetric ceram
Ivoclare vivadent)
Orthodontic band was removed and
the tooth was prepared to receive
a metal crown(fig.6).
crown was cemented initiall
followed by full metal crown(fig.7).
Volume 1 Issue 2
September 2010
p chamber and the
The root canal
treatment was completed and
temporary restoration was given.
Fractured line running mesiodistally
shown under magnification
In the subsequent
appointment temporary restoration
was removed, access cavity was
thoroughly debrided with saline
and dried. Self etching adhesive
(Multilink) was applied to the
manufacturer’s
instructions and the cavity was
restored with packable light cured
composite resin (Tetric ceram –
(fig.4&5).
Orthodontic band was removed and
epared to receive
ig.6). Temporary
crown was cemented initially
followed by full metal crown(fig.7).
Management of Vertically Fractured Maxillary Second
Molar
48 Journal of Dental Sciences and Research
Fig4: Post Obturation Radiograph.
Fig5: Access cavity restored with
composite resin splinting the buccal &
Lingual fragments.
Fig6: Tooth Preparation done to Receive a
Metal Crown.
Fig7: Metal Crown Cemented on Maxillary
Second Molar.
f Vertically Fractured Maxillary Second Volume 1 Issue 2
September 2010
Journal of Dental Sciences and Research
Fig4: Post Obturation Radiograph.
Access cavity restored with
splinting the buccal &
h Preparation done to Receive a
Fig7: Metal Crown Cemented on Maxillary
Tooth is periodically
evaluated once in a month.
Tenderness to percussion has
gradually reduced and the patient
is able to chew on the tooth.
Periodontal attachment is intact
without pocket formation. IOPA
radiograph does not show any sign
of bone loss in the furcation or
interdental area. Further periodic
evaluation is planned once in three
months till one year and later once
a year to know the long term
success of the treatment.
Discussion:
Tooth fractures include
trauma related crown, crown
fractures and a broad group of
cracked teeth. American
association of Endodontists classify
cracked teeth as4 –
Cuspal fractures
Cracked teeth
Split tooth
Vertical root fracture.
Split tooth fractures are
primarily mesio distal fractures
that cross both marginal ridges and
extend deep to shear onto the root
Volume 1 Issue 2
September 2010
Tooth is periodically
evaluated once in a month.
Tenderness to percussion has
gradually reduced and the patient
is able to chew on the tooth.
ontal attachment is intact
ormation. IOPA
radiograph does not show any sign
bone loss in the furcation or
interdental area. Further periodic
evaluation is planned once in three
months till one year and later once
a year to know the long term
success of the treatment.
Tooth fractures include
a related crown, crown-root
and a broad group of
cracked teeth. American
association of Endodontists classify
Craze lines
Cuspal fractures
Vertical root fracture.
Split tooth fractures are
primarily mesio distal fractures
that cross both marginal ridges and
extend deep to shear onto the root
Management of Vertically Fractured Maxillary Second
Molar Volume 1 Issue 2
September 2010
49 Journal of Dental Sciences and Research
surface. The more centered the
fracture is occlusally, the greater
the tendency to extend apically.
These fractures are more
devastating. Mobility of one or both
segments will be present. These
fractures usually include the pulp.
Maintaining an intact tooth is
challenging if not impossible.
Prognosis is variable. When the
fracture extends to and surfaces in
the middle to cervical third of the
root, there is reasonable chance of
successful treatment and
restoration.
There are various treatment
modalities in the literature to bind
cracked teeth together, like the use
of adhesives, amalgam with
retention on both sides of the
infractions and full coverage
crowns, and experimental
approaches using lasers CO2, Nd-
YAG.
The outcome of the
treatment is not extensively
reported for teeth with infractions.
Cameron reported a 75% success
after 10 years following the
placement of the crowns. Guthrie
and Defiore found that 24 of 25
teeth restored with acrylic crowns
were asymptomatic after one year.
Brynjulfsen et al achieved pain
relief in 90% of their patients after
protective restorations including
endodontic treatment. Tan etal
showed an 85% survival rate of 2
years after protective crowns were
placed. According to Leif K Bakland
a 5 year survival prediction
appears reasonable in most cases.
Dr.David A Hall has followed his
cases upto 20 years where a split
tooth can be completely salvaged,
intact and fully healthy when
repositioned early and stabilized
where the healing was observed by
cementum deposition5.
In the present case report
the fracture in maxillary right
second molar was almost centered
running mesiodistally involving
both the marginal ridges and the
pulp cavity similar to one of the
case reports by Dr David A Hall.
Root canal treatment was carried
out under orthodontic band
Management of Vertically Fractured Maxillary Second
Molar Volume 1 Issue 2
September 2010
50 Journal of Dental Sciences and Research
cementation. Later the tooth
fragments were splinted with self
etching adhesive, restored with
light cured composite resin and a
full metal crown was cemented.
The tooth is followed up for 6
months with no signs of failure.
Treating longitudinal
tooth fractures is challenging and
long term follow up is necessary.
References:
1. Eric M Rivera, Richard E Walton.
Longitudinal tooth fractures. In:
Endodontics principles and
practice. 4th ed. Saunders :
Elsevier. Inc. 2009.p 108-28.
2. David A Hall, Sergio A M
Qurique, Guilherme H Itikawa.
Brazilian dental journal Jan-Feb
2004. p 10-15.
3. Masaka N. Long term
observation of fractured tooth
roots preserved by adhesion.
Adhesive Dentistry.
1995;13:156-70.
4. Leif K Bakland. Tooth
infractions. In: Endodontics. 6th
ed. Hamilton:B C Decker Inc.
2008. p 660-75.
5. Hall D A. Restoration of a
shattered tooth – report of a
case. Jour. Americ. Dent. Assoc.
1998; Jan : 129-35.
Corresponding author address:
Dr. Jyothi K.N.
No: 101, Swajyothi, 2ND Cross, 4TH
Main, Income Tax Layout, Near
Attiguppe Vijayanagar, Bangalore.-
560040.
PH. 080-23396000, 9845184346.
E- Mail: [email protected]
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