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Table of Contents
CASE REPORT
Year : 2011  |  Volume : 1  |  Issue : 1  |  Page : 49-54

Management of subgingivally fractured teeth: A multidisciplinary approach


1 Departments of Orthodontics and Dentofacial Orthopedics, A.M.E's Dental College, Hospital and Research Center, Raichur, Karnataka, India
2 Department of Conservative Dentistry and Endodontics, A.M.E's Dental College, Hospital and Research Center, Raichur, Karnataka, India

Date of Web Publication4-Mar-2011

Correspondence Address:
Raghu Devanna
Departments of Orthodontics and Dentofacial Orthopedics, A.M.E's Dental College, Hospital and Research Center, Raichur, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.77209

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   Abstract 

The interdisciplinary treatment is becoming an ever-increasing part of modern-day orthodontic practice. Subgingivally fractured incisors pose a true therapeutic dilemma to the dental team. Attempts to expose the fracture line by alveolar re-contouring and periodontal procedures may compromise the functional root length and esthetics. Placing the margin of the restoration in the biologic width frequently leads to chronic gingivitis, the loss of clinical attachment, pockets and gingival recessions. Controlled orthodontic extrusion is considered as the easiest orthodontic tooth movement to expose the fracture line, which can produce excellent results with a good prognosis and a low risk of relapse. This case report describes in detail the chosen treatment for subgingivally fractured permanent incisors and is followed by a discussion of the considerations involved in the choice of treatment.

Keywords: Subgingivally fractured teeth, controlled orthodontic extrusion, multidisciplinary management


How to cite this article:
Devanna R, Hegde V, Kavitha V. Management of subgingivally fractured teeth: A multidisciplinary approach. J Interdiscip Dentistry 2011;1:49-54

How to cite this URL:
Devanna R, Hegde V, Kavitha V. Management of subgingivally fractured teeth: A multidisciplinary approach. J Interdiscip Dentistry [serial online] 2011 [cited 2019 Sep 17];1:49-54. Available from: http://www.jidonline.com/text.asp?2011/1/1/49/77209

The prime use of orthodontic tooth movement to enhance endodontic procedures and tooth retention is the realm of root or tooth extrusion. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Common indications for this procedure include fractured tooth margins below crestal bone, deep carious margins in teeth requiring root canal treatment, resorptive perforations, postspace preparation perforations, aberrant coronal access openings, and some isolated infrabony defects. [8] The prime objective of tooth extrusion or forced eruption is to provide both a sound tissue margin for ultimate restoration and to create a periodontal environment (biological width) that will be easy for the patient to maintain. The use of root extrusion, in conjunction with periodontal crown lengthening, has saved many good teeth from extraction. [10] This case report details a multidisciplinary management of such subgingivally fractured incisor teeth.


   Case Report Top


A male patient aged 19 years, reported to Department of Oral medicine with the chief complaint of fracture of upper right front teeth 20 days back.

He gave history of trauma (bike accident) 20 days back with a mild type of pain which was continuous. The patient's medical and family histories were non contributory, and the results of the extra oral examination were unremarkable.

Intra -oral assessment

Intra-oral examination revealed a chisel type fracture and missing maxillary right canine [[Figure 1]a, b]. On radiological examination, the remaining roots appeared to have sufficient length, width and taper without any fracture, to consider extrusion [[Figure 1]c]
Figure 1: (a)Pretreatment intraoral frontal
Figure 1b: Pretreatment intraoral occlusal
Figure 1c: Pretreatment of IOPA


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Treatment aims

These were as follows:

  • Cleaning, shaping and obturation of the upper right central and lateral incisors;
  • Orthodontic extrusion of upper right central and lateral incisors;
  • Crown lengthening of upper right central and lateral incisors;
  • Cast post and core and metal ceramic bridge to restore esthetics.


Treatment plan

  • Among the treatment options for such cases, orthodontic extrusion was considered as the best choice.
  • The treatment plan consisted of multidisciplinary approach for plaque control, conservative and endodontic treatment, orthodontic extrusion, periodontal surgery and prosthodontic restoration.


Treatment progress

A conservative access opening was prepared to extirpate the pulp and working length radiograph was taken. Cleaning, shaping and obturation were done [[Figure 2]a-c].
Figure 2: (a)Working length determination
Figure 2b: Cleaning, shaping and master cone
Figure 2c: Root canal therapy completed


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The orthodontic treatment consisted of forced eruption of the root of the fractured maxillary right central and lateral incisors. By considering the estimated crown root ratio and the extension of the fracture, 4 mm extrusion was considered as adequate to provide sufficient biologic width as well as to provide a ferrule for the final restoration. Extrusion force of about 40-60 g was applied. Pericision was performed before and during the extrusion procedure. After six weeks, 4 mm of extrusion was observed, and then the appliance was made passive [[Figure 3]a-d]. Corrective periodontal surgical procedure was performed. Ridge augmentation in the upper right canine region and crown lengthening of upper right central and lateral incisors were done [Figure 4] and [Figure 5]. Cast post and core was given [Figure 6]. Metal ceramic bridge was planned [[Figure 7]a, b]. A pre- and post treatment comparison reveals an excellent esthetic result [Figure 8].
Figure 3: (a)Orthodontic bonding
Figure 3b: Application of elastic force
Figure 3c: Tooth extrusion as a result of orthodontic force application
Figure 3d: Post orthodontic extrusion


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Figure 4: Ridge augmentation for 13

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Figure 5: Crown lengthening procedure for 11 and 12

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Figure 6: Post and core fabrication done for 11 and 12

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Figure 7: (a)Metal ceramic crown restoration frontal view
Figure 7b: Metal ceramic crown restoration occlusal view


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Figure 8: Pre treatment and post treatment comparison

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   Discussion Top


This case report documents a successfully treated case of subgingivally fractured teeth with a multidisciplinary approach. Delivanis et al. detailed a case report where the fracture of the crown of the tooth extended below the alveolar crest and the tooth was saved through an endodontic-orthodontic approach. Following pulpotomy, orthodontic attachments were directly bonded to the two teeth on either side of the fractured tooth. The fractured crown received a direct bonded button placed as high gingivally as possible. A sectional archwire was fitted to the adjacent teeth and an elastic force was used to extrude the fractured tooth. [4] Simon et al. indicated that the orthodontic extrusion should become a routine procedure in dentistry. They also stressed that the orthodontically extruded tooth must be stabilized for 8-12 weeks prior to fabrication of a permanent post and core. [2] We have also found that 8-12 weeks of stabilization of orthodontically extruded teeth has better prognosis.

Stern and Becker discussed orthodontic extrusion as an esthetic alternative to surgical crown lengthening and lowering of the alveolar crest 2-3 mm. They indicated that with an extrusive force, there was additional bone deposition lining the socket. Unlike other orthodontic procedures, in extrusion, bone resorption does not occur. Bundle bone is replaced by lamellar bone. [6] If excessive forces are used, however, significant pulpal changes or necrosis may easily result. [11] They also indicated that Begg brackets and a multistranded wire allowed for three times the interbracket length whilst allowing a decrease in eruptive force of 27 times, thereby reducing concerns over necrosis and resorption. [11] Rapid extrusion may produce limited amounts of resorption over a short time span, but with long-term assessments are unavailable. [12] Following a histological assessment, Simon et al. indicated that extrusion of endodntically treated teeth did not present any apparent problems. They reported that the alveolar housing moves occlusally as the tooth is extruded followed by bone deposition at the alveolar crest and throughout the interradicular area. [3] These findings corroborated with those of Ingber. [1],[13] Subsequently, additional contouring of the gingiva or osseous recontouring (crown lengthening) is usually required to optimize esthetic results and the biologic width. Apical radiolucencies noted from the extrusion were normal by the fourth week and the PDL was normal after seven weeks. New bone was evident at the alveolar crest, interradicular, and apical areas. [13]

Biggerstaff et al. found that using 20-30 g of eruptive force resulted in eruption with alveolar crestal new bone, which coupled with a biologic width realignment procedure, afforded superior esthetic to crown lengthening procedures only. [8] Similarly, periodontal implications of orthodontic tooth movements were studied by Polson et al. by creating intrabony periodontal angular pockets on the mesial and distal areas of incisors in rhesus monkeys. The teeth were moved through these defects, ultimately eliminating the angular defects. [14] Since the ultimate success of any endodontic procedure relies on how well the tooth is ultimately restored, orthodontic tooth movement can be used to enhance embrasure space in teeth that are endodontically treated. [10],[15]


   Conclusion Top


Adjunctive orthodontic root extrusion and root separation are essential clinical procedures that will enhance the integrated treatment planning process of tooth retention in endodontic-orthodontic related cases. Extrusion of a fractured tooth has several advantages over extraction and prosthodontic replacement. It is a conservative approach that preserves the natural tooth and maintains the periodontal architecture. A disadvantage of the approach is the long treatment duration compared to extraction and replacement.

Careful evaluation of the case is of utmost importance to achieve the best possible results which includes planned utilization of the multidisciplinary approach. The treatment modality should be focused toward the treatment outcome in terms of function and esthetics.

We have successfully used the technique described above in several patients. All these patients showed satisfactory periodontal health after treatment.

 
   References Top

1.Ingber JS. Forced eruption: Part I. A method of treating isolated one or two wall infrabony osseous defects rationale and case report. J Periodontology 1974;45:199-206.  Back to cited text no. 1
    
2.Simon JHS, Kelly WH, Gordan DG, Ericksen GW. Extrusion of endontically treated teeth. JADA 1978;97:17-23.  Back to cited text no. 2
    
3.Simon JHS, Lythgoe JB, Torabinejad M. Clinical and histological evaluation of extruded endodontically treated teeth in dogs. Oral Surg Oral Med Oral Pathol 1980;50:361-71.  Back to cited text no. 3
    
4.Delivanis P, Delivanis H, Kuftinec MM. Endodontic- orthodontic management of fractured anterior teeth. JADA 1978;97:483-5.  Back to cited text no. 4
[PUBMED]    
5.Ivey DW, Calhoun RL, Kemp WB, Dorfman HS. Orthodontic extrusion: its use in restorative dentistry. J Pros Dentis 1980;43:401-7.  Back to cited text no. 5
    
6.Stern N, Becker A. Forced eruption: biological and clinical considerations. J Oral Rehabili 1980;7:395-402.  Back to cited text no. 6
    
7.Garret GB. Forced eruption in the treatment of transverse root fractures. JADA 1985;111:269-72.  Back to cited text no. 7
    
8.Biggerstaff RH, Sinks JH, Carazola AL. Orthodontic extrusion and biologic width realignment procedures: methods for reclaiming non restorable teeth. JADA 1986;112:345-8.  Back to cited text no. 8
    
9.Weine FS. Endodontic Therapy. 5 th ed. St Lois. MO, USA: Mosby- Yearbook; 1996. P . 674-92.  Back to cited text no. 9
    
10.Lovdahl PE, Wade CK. Problems in tooth isolation and periodontal support for the endodontically compromised tooth. In: Gutmann JL, Dumsha TC, Lovdahl PE, Hovland JE, editors. Problem solving in endodontics. 3 rd ed. St. Louis, MO, USA: Mosby Co; 1997. p. 203-28.   Back to cited text no. 10
    
11.Mostafa YA, Iskander KG, El-mangoury NH. Iatrogenic pulpal reactions to orthodontic extrusion. AJO-DO 1991;99:30-4.  Back to cited text no. 11
    
12.Malmgren O, Malmgren R, Frykohlm A. Rapid orthodontic extrusion of crown root and cervical root fractured teeth. Endod Dent Traumato 1991;7:49-54.  Back to cited text no. 12
    
13.Ingber JS. Forced eruption: Part II. A method of treating nonrestorable teeth periodontal and restorative considerations. J Periodont 1976;47:203-16.  Back to cited text no. 13
[PUBMED]    
14.Polson A, Caton J, Polson AP, Nyman S, Novak J. Periodontal response after tooth movement into intrabony defects. J Periodont 1984;55:197-202.  Back to cited text no. 14
    
15.Casullo DP, Matarazzo FS. The preparation and restoration of the multi-rooted tooth with furcation involvement. Chicago, IL, USA: Quintessence Publishing Co; 1980. p. 232-53  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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