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Table of Contents
CASE REPORT
Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 133-136

Multidisciplinary approach for treatment of sub gingival crown fracture


1 Department of Conservative Dentistry and Endodontics, Uttar Pradesh Dental College and Research Centre, Lucknow, India
2 Department of Periodontics, Uttar Pradesh Dental College and Research Centre, Lucknow, India

Date of Web Publication17-Sep-2011

Correspondence Address:
Smita Govila
Department of Conservative Dentistry and Endodontics, Uttar Pradesh Dental College and Research Centre, Lucknow
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.85041

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   Abstract 

Traumatic injuries of the teeth and their structures are complex and require comprehensive, accurate diagnosis and a multidisciplinary approach for successful treatment outcome. The article emphasizes the need for a planned multidisciplinary approach to treat subgingival crown fracture, keeping into consideration the biological, functional, esthetic and patient demands. The fractured tooth was endodontically treated with post and core placement, orthodontically extruded and soft tissue contours corrected for crown placement.

Keywords: Biologic width, crown fracture, dental trauma, traumatic injuries


How to cite this article:
Govila S, Govila V, Rajkumar B. Multidisciplinary approach for treatment of sub gingival crown fracture. J Interdiscip Dentistry 2011;1:133-6

How to cite this URL:
Govila S, Govila V, Rajkumar B. Multidisciplinary approach for treatment of sub gingival crown fracture. J Interdiscip Dentistry [serial online] 2011 [cited 2019 Oct 13];1:133-6. Available from: http://www.jidonline.com/text.asp?2011/1/2/133/85041


   Introduction Top


Coronal fracture of the anterior teeth is a common form of dental trauma that mainly affects children and adolescents. [1],[2] The majority of dental injuries involves the anterior teeth, especially the maxillary incisors (because of its position in the arch), it usually affect a single tooth; however, certain traumas such as automobile accidents and sports injury can involve multiple teeth. [3] Esthetic rehabilitation of crown fracture of the maxillary anterior tooth is one of the greatest challenge to the dental surgeon. Several factors influence the management of crown fracture which include extent of fracture (biological width violation, endodontic involvement, alveolar fracture), pattern of fracture and restorability of fractured tooth (associated root fracture), secondary trauma injuries (soft tissue status), presence or absence of fractured tooth fragment and its condition, occlusion, esthetics, finances, and prognosis. [4],[5],[6] Fracture of a tooth below the gingival attachment or crest of the alveolar bone presents a very complicated restorative problem. Heithersay suggested that orthodontic extrusion along with crown lengthening procedure which involves the removal of supporting alveolar bone is the treatment of choice for subgingival fracture of crown of single rooted tooth. [1],[2],[3],[4],[5],[6],[7] However, during the treatment, biologic width can be compromised which can be restored following extrusion by orthodontic treatment utilizing various splints and modified Hawley appliances to obtain proper contour of the gingiva, as 3-4 mm distance from the alveolar crest to the coronal extension of the remaining tooth structure has been recommended for optimal periodontal health. [8],[9]

Anatomic considerations

The average biologic width is 2.04 mm, it comprises gingival connective tissue and epithelial attachment in the form of the functional epithelium. It is of prime importance when considering the restoration of the tooth whose gingival margin is at the level or below the alveolar crest. An additional 1-2 mm of the sound tooth structure should be available coronal to the epithelial attachment to place the margin of a restoration. The distance from the alveolar crest to the coronal extent of the remaining tooth structure should be at least 3-4 mm, if it is less there is a risk of impinging upon the functional epithelium and connective tissue attachment in a sub gingival preparation. [10]


   Case Report Top


A 25-year-old man was referred to the Department of Conservative Dentistry and Endodontics, U.P. Dental College and Research Centre, Lucknow, two days after sustaining a complicated crown fracture involving enamel, dentin and pulp of his maxillary right central incisor due to a road accident [Figure 1]. No history of allergy or systemic problems was reported and family history was also non contributory. An extra oral examination revealed swelling of the upper lip. Intraoral clinical examination showed no lacerations or evidence of alveolar fracture or gingival inflammation and vitality test demonstrated it to be nonvital.
Figure 1: Sub gingival crown fracture

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Radiographic findings

An intra oral periapical radiograph revealed complete root apex closure in the maxillary right central incisor; the crown had sustained an oblique fracture which extended up to the cervical level. No periapical pathology or root fracture was observed.

Treatment plan

The patient was given detailed information regarding the treatment procedure and written consent was obtained. Maxillary right central incisor had sustained an uncomplicated crown fracture which extended to the cervical level. The mobile portion of the tooth was removed [Figure 2]. The root was endodontically treated and routine oral prophylaxis was carried out. A major concern in this case was the sub gingival fracture in the tooth which required a crown lengthening procedure. Reshaping of the bony architecture both buccal and the palatal aspect around the involved tooth was carried out to get a smooth flow, and periodontal pack was subsequently placed [Figure 3] and [Figure 4].
Figure 2: Fractured part of the tooth removed

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Figure 3: Flap reflected for reshaping the bony architecture

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Figure 4: Periodontal pack applied

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Post space was prepared for the placement of J shaped wire which was cemented with zinc phosphate cement [Figure 5]. Zinc phosphate cement was selected for cementation because of its adequate strength and ease of removal. Orthodontic brackets with wire were placed from central incisor to pre-molars in such a way that adaptation was carried out without interfering with the occlusion [Figure 5]. Initially reduced amount of forces was applied for a week followed by greater force for six months till adequate extrusion occurred and stabilization was done with high resilient stainless steel wire for three months to allow sufficient time for healing of the socket.
Figure 5: Crown lengthening carried out by orthodontic extrusion

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After nine months, tooth was firm and an extrusion of 1.5 mm was achieved which was sufficient for the post placement, but still tooth surface was proximally inadequate for the preparation of the ferrule for fabrication of the crown [Figure 6]. After the placement of fiber cast post and building of the core, [Figure 7],[Figure 8],[Figure 9] electrosurgery was carried out to recontour the gingiva and increase the length of the crown. It was followed by temporization with acrylic crown whereas the left central incisor was restored with composite. After one month, the temporary crown was replaced by a metal ceramic crown [Figure 10]. Thus with this treatment regime both the hard and soft tissue esthetics was maintained.
Figure 6: Fiber post cemented IOPA

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Figure 7: Fiber post cemented

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Figure 8: Core built up

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Figure 9: Crown lengthening by electro surgery

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Figure 10: Metal ceramic crown cemented

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   Discussion Top


The basic philosophy of modern dentistry is prevention of diseases and conservation of the functional members of the dental arch. Traumatic injuries of the teeth and their supporting structures has been and continues to be a challenge, which every dental professional must be prepared to assess and treat efficiently. They occur most frequently in children with accident-prone profile. Accidents, falls, blows and trauma during sports are the primary reasons for these injuries. Rational therapy depends on accurate diagnosis, an effective evaluation of patients' medical history, immunization status, general physical condition and neurologic status of patient. In this case, the root portion below the fracture was sufficient to support a restoration, but very difficult to prepare because of the poor visibility and access. Treatment options with preservation of the root which are generally recommended are clinical crown lengthening and orthodontic extrusion. Surgical crown lengthening alone is not indicated as it would have lead to very high gingival contour of central incisor hampering the soft tissue esthetics. Thus orthodontic extrusion followed by surgical crown lengthening was decided as the treatment modality for this case, thus the treatment was divided into three phases: periodontic phase, orthodontic phase, and a restorative phase.


   Conclusion Top


The necessity for an interdisciplinary approach for treatment of routine dental problems has been recognized for a long time. In this case the intervention of an endodontist, an orthodontist, a periodontist and a prosthodontist was essential in the treatment of subgingivally fractured crown. It is understandable that without the cooperation between specialists, the tooth could not have been saved and restored routinely, leading to a functional and esthetically satisfying result. The key to success are the right indications for the treatment and the dedication of the dentist to reassure and motivate the patient throughout the whole course of treatment, as well as institute a strict and regular recall regimen to guarantee a long-term successful prognosis.

 
   References Top

1.Dietschi D, Jacoby T, Dietschi JM, Schatz JP. Treatment of traumatic injuries in the front teeth: Restorative aspects in crown fractures. Pract Periodontics Aesthet Dent 2000;12:751-8.  Back to cited text no. 1
[PUBMED]    
2.Hamilton FA, Hill FJ, Holloway PJ. An investigation of dento-alveolar trauma and its reatment in an adolescent population. Part 1: The prevalence and incidence of injuries and the extent and adequacy of treatment received. Br Dent J 1997;182:91-5.  Back to cited text no. 2
[PUBMED]    
3.Andreasen JO, Andreasen F, Andersson L. Textbook and color atlas of traumatic injuries to the teeth. 3 rd ed. St Louis (MO): Mosby; 1994.  Back to cited text no. 3
    
4.Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: Pulpal and restorative considerations. Dent Traumatol 2002;18:103-15.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Reis A, Francci C, Loguercio AD, Carrilho MR, Rodriques Filho LE. Re-attachment of anterior fractured teeth: Fracture strength using different techniques. Oper Dent 2001;26:287-94.  Back to cited text no. 5
[PUBMED]    
6.Andreasen FM, Norén JG, Andreasen JO, Engelhardtsen S, Lindh-Strömberg U, et al. Long term survival of fragment bonding in the treatment of fractured crowns. Quintessence Int 1995;26:669-81.  Back to cited text no. 6
    
7.Baratieri LN, Ritter AV, Junior SM, Filho JC. Tooth fragment reattachment: An alternative for restoration of fractured anterior teeth. Pract Periodont Aesthet Dent 1998;10:115-27.  Back to cited text no. 7
    
8.El-Askary FS, Ghalab OH, Eldemerdash FH, Ahmed OI, Fouad SA, Nagy MM. Reattachment of a severely traumatized maxillary central incisor, one-year clinical evaluation: A case report. J Adhes Dent 2006;8:343-9.  Back to cited text no. 8
[PUBMED]    
9.Rappelli G, Massaccesi C, Putignano A. Clinical procedures for the immediate reattachment of a tooth fragment. Dent Traumatol 2002;18:281-4.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Reis A, Loguercio AD, Kraul A, Matson E. Reattachment of fractured teeth: A review of iterature regarding techniques and materials. Oper Dent 2004;29:226-33.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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