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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 38-40

Multidisciplinary approach for esthetic management of crown-root fracture: Orthodontic extrusion and prosthetic rehabilitation


Conservative Dentistry and Endodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication29-May-2017

Correspondence Address:
Shreya Sharma
Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_58_15

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   Abstract 

Fracture of anterior teeth poses functional as well as esthetic implications. Subgingival fractures are often treated by extraction of tooth followed by implant placement or a conventional fixed partial denture due to absence of adequate ferrule at the fracture site. Orthodontic extrusion/forced eruption can aid in the traction of fractured plane coronal to the gingival level, providing enough tooth structure for prosthetic rehabilitation. Since the surrounding periodontium also remodel during tooth extrusion, periodontal intervention may be required for their recontouring leading to a more esthetic final result. Endodontics need to be carried out when the pulp is involved due to traumatic injury. This kind of multidisciplinary approach can save many teeth with subgingival fracture from extraction. It can save the patient from the stress of extraction, especially at young age.

Keywords: Biological width, ferrule, forced eruption, subgingival fracture


How to cite this article:
Sharma S, Mittal N. Multidisciplinary approach for esthetic management of crown-root fracture: Orthodontic extrusion and prosthetic rehabilitation. J Interdiscip Dentistry 2017;7:38-40

How to cite this URL:
Sharma S, Mittal N. Multidisciplinary approach for esthetic management of crown-root fracture: Orthodontic extrusion and prosthetic rehabilitation. J Interdiscip Dentistry [serial online] 2017 [cited 2020 Dec 3];7:38-40. Available from: https://www.jidonline.com/text.asp?2017/7/1/38/207155


   Clinical Relevance to Interdisciplinary Dentistry Top


  • Complicated crown-root fractures, especially in anterior esthetic zone, can be treated by interdisciplinary approach
  • Endodontic treatment of traumatized tooth, followed by orthodontic extrusion, will provide the desired ferrule effect
  • Periodontal management of gingival tissue will aid in healing and improved esthetics
  • Teeth with immature apex also have a chance of survival following traumatic injury if this multidisciplinary approach is followed meticulously.



   Introduction Top


Traumatic injuries to anterior teeth pose a great challenge to a dentist. The tooth needs to be restored to proper esthetic, structural, and functional entity. Further, in case of subgingival fractures, prognosis of fractured tooth is considered questionable or hopeless. With the dentist's increasing inclination toward dental implants, extraction has become the most common treatment modality for such cases. This, however, should not be the approach. Every attempt should be made to preserve and restore the natural tooth structure. In order to save such a tooth, a multidisciplinary approach including endodontics, periodontal crown lengthening, and/or orthodontic extrusion followed by prosthetic rehabilitation is needed.

In subgingival fracture, there is absence of adequate coronal ferrule. This hampers the prosthetic treatment. Surgical crown lengthening involves the removal of supporting crestal alveolar bone while orthodontic crown lengthening forcibly extrudes the tooth. Both these procedures increase the length of clinical crown and expose sufficient coronal tooth structure for proper prosthetic restoration. However, surgical crown lengthening procedures may expose excess of root and may compromise esthetic results. This can be avoided by the use of orthodontic forced eruption.[1],[2],[3],[4] Forced eruption provide a sound tooth margin for prosthetic restoration and create a periodontal environment that is easy for the patient to maintain.

This case required increase in the length of clinical crown for providing adequate ferrule for the prosthesis. Orthodontic extrusion was done. Periodontal intervention is required because the gingival margin needs to be similar to that of adjacent central incisor for esthetic reasons. Endodontic intervention using a bonded fiber post and a composite core build-up added to the stability of the fractured tooth by forming a monobloc. Finally, prosthetic procedure was done for the final restoration. In this way, multidisciplinary approach leads to retention and restoration of this tooth.


   Case Report Top


A 15-year-old male patient reported with the chief complaint of fractured upper front tooth. He had history of trauma 5 years back. Clinical examination showed oblique coronal fracture of upper right central incisor (#11) without exposed pulp tissue [Figure 1]a. The fractured line extended subgingivally on the distal side. Mesial half of the tooth structure was intact. There was no any mobility. Radiographic examination revealed an immature apex without any periapical lesion or any sign of additional root fracture. The patient had mineral trioxide aggregate (MTA) apexification done by a dentist 5 years back [Figure 1]b. The patient again suffered trauma while playing 6 months back, and the tooth fractured.
Figure 1: (a) Preoperative photograph showing fractured tooth #11. (b) Preoperative radiograph showing mineral trioxide aggregate apexification

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The patient was given the option of extraction or a multidisciplinary treatment for esthetic restoration of tooth #11. The patient opted for the latter. With his father's consent, orthodontic extrusion was planned. After confirming the asymptomatic status of the tooth, rapid orthodontic extrusion was done using 0.022 slot MBT brackets and 0.014″ NiTi wire bonded to adjacent teeth (right #15 to left #25 teeth) [Figure 2]a. Based on the amount of ferrule required, it was planned to extrude the tooth to about 2 mm. After 1 week, the tooth had extruded around 2 mm, sufficient enough to provide a ferrule of 1 mm on distal side. Tooth extrusion at this point was considered adequate, and the extruded tooth was stabilized by splinting to the original wire with direct composite for a period of about 4 weeks.
Figure 2: (a) Orthodontic brackets placed for extrusion. (b) After 2 mm extrusion, brackets were removed

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After the stabilization period, definitive coronal restoration was planned [Figure 2]b. Gingival recontouring was done to have a gingival margin symmetric to the left central incisor [Figure 3]a and [Figure 3]b. After healing of the recontoured gingiva, the remaining coronal structure was assessed, and it was judged to be adequate to retain a definitive full-coverage restoration [Figure 3]c. Intra-radicular support was provided by fiber post. Postspace was made in the root canal using Peeso Reamers. Fiber post was bonded to the root dentin using resin cement. Coronal core build-up was done using composite resin [Figure 4]a. Tooth preparation was done, and a full-coverage porcelain fused to metal crown was given [Figure 4]b.
Figure 3: (a) Periodontal surgery for recontouring for gingival tissues. (b) Gingival tissues recontoured. (c) Healing after periodontal surgery

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Figure 4: (a) Core build up with composite resin. (b) Metal ceramic crown placed

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   Discussion Top


In subgingival fractures, adequate coronal structure for ferrule is not present. If restorative margins are placed within the biologic width, gingival inflammation, clinical attachment loss, and bone loss will occur. Ingber et al. suggested that there should be a minimum distance of 3 mm between the restorative margin and the alveolar crest for a restoration to be biologically acceptable.[5] Orthodontic extrusion is preferred over surgical crown lengthening considering that the supporting bone is sacrificed and there is a negative change in the length of the clinical crowns of both the tooth and its neighbors when surgical crown lengthening is done.[6] Extrusion involves applying tractional forces in all regions of the periodontal ligament to stimulate marginal apposition of crestal bone. Since the gingival tissue is attached to the root by connective tissue, the gingiva follows the vertical movement of the root during the extrusion process. Similarly, the alveolus is also pulled along by the movement of the root.[7]

If the length of the root is sufficient to support a coronal restoration, then the tooth can be endodontically treated followed by orthodontic extrusion to bring the fracture plane above the gingival margin. In slow extrusion, bone and gingival movements are also produced. However, in rapid extrusion, coronal migration of the supporting tissues is less because the rapid movement exceeds their capacity for physiologic adaptation.[4] Thus, rapid extrusion was done in this case to prevent movement of the gingival collar and alveolar bone along with the tooth. This was in accordance with the previously reported cases.[6],[8],[9] Rapid orthodontic extrusion is done at higher forces, around 50 g,[10] so longer retention periods are also required to stabilize the tooth and for remodeling and adaptation of the periodontium. Had the restoration been placed, without extrusion, then it would have encroached on the biological width. Furthermore, the ferrule had been inadequate for the long-term success of the restoration.

Periodontal management is required after coronal movement of the periodontal attachment has occurred.[7] Gingival recontouring forms an essential part of the esthetic management. It is only after the gingival healing that the adequacy of the coronal structure can be confirmed. The restorative procedure required a monobloc to increase the strength of the remaining tooth structure as it was an immature tooth with MTA apexification. Bonding of fiber post to the dentin walls and formation of a resin core served this purpose. Final prosthesis was a metal ceramic crown, luted over the core. The patient's father asked for a more economic metal ceramic crown as compared to an all-ceramic crown.

For the present case, the insufficient coronal tooth structure on the distal side left us with the option of either extraction followed by implant or retaining the root fragment with subsequent rehabilitation. The option of implant was rejected by the patient due to the high cost involved. This interdisciplinary approach helped us meet the structural, functional, and esthetic demands of the patient, that too, at a cost which was comfortable for the patient to bear.


   Conclusion Top


A series of permutations and combinations should be discussed while planning the treatment of traumatic injuries. Extraction must be used as the last resort rather than the foremost intervention. A multidisciplinary approach can help save teeth which pose a challenge to the dentist. It can also save the patient from the mental stress of extraction of tooth, especially at young age. Orthodontic extrusion is a conservative procedure that allows retention of a tooth. This simple technique requires a relatively easy movement and helps in subsequent restoration of the tooth. It can be considered as a savior for both the natural tooth and its supporting tissues.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Johnson RH. Lengthening clinical crowns. J Am Dent Assoc 1990;121:473-6.  Back to cited text no. 1
    
2.
Ivey DW, Calhoun RL, Kemp WB, Dorfman HS, Wheless JE. Orthodontic extrusion: Its use in restorative dentistry. J Prosthet Dent 1980;43:401-7.  Back to cited text no. 2
    
3.
Fournier A. Orthodontic management of subgingivally fractured teeth. J Clin Orthod 1981;15:502-3.  Back to cited text no. 3
    
4.
Simon JH, Kelly WH, Gordon DG, Ericksen GW. Extrusion of endodontically treated teeth. J Am Dent Assoc 1978;97:17-23.  Back to cited text no. 4
    
5.
Ingber JS, Rose LF, Coslet JG. The “biologic width” – A concept in periodontics and restorative dentistry. Alpha Omegan 1977;70:62-5.  Back to cited text no. 5
    
6.
Maitin N, Maitin S, Rastogi K, Bhushan R. Aesthetic management of a complicated crown fracture: A multidisciplinary approach. BMJ Case Rep 2013;2013. pii: Bcr2013009643.  Back to cited text no. 6
    
7.
Bach N, Baylard JF, Voyer R. Orthodontic extrusion: Periodontal considerations and applications. J Can Dent Assoc 2004;70:775-80.  Back to cited text no. 7
    
8.
Goenka P, Marwah N, Dutta S. A multidisciplinary approach to the management of a subgingivally fractured tooth: A clinical report. J Prosthodont 2011;20:218-23.  Back to cited text no. 8
    
9.
Patil PG, Nimbalkar-Patil SP, Karandikar AB. Multidisciplinary treatment approach to restore deep horizontally fractured maxillary central incisor. J Contemp Dent Pract 2014;15:112-5.  Back to cited text no. 9
    
10.
Bondemark L, Kurol J, Hallonsten AL, Andreasen JO. Attractive magnets for orthodontic extrusion of crown-root fractured teeth. Am J Orthod Dentofacial Orthop 1997;112:187-93.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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