Journal of Interdisciplinary Dentistry

SHORT COMMUNICATION
Year
: 2012  |  Volume : 2  |  Issue : 3  |  Page : 221--224

Orthodontic extrusion and biologic width realignment procedures for rehabilitation in a permanent premolar with an extensive dental fracture


Josué Martos, Aline Pinheiro de Moraes, Camila Severo Carlos, Luis Eduardo Rilling da Nova Cruz, Luiz Fernando Machado Silveira 
 Department of Semiology and Clinics, Faculty of Dentistry, University Federal of Pelotas, Pelotas, Brazil

Correspondence Address:
Josué Martos
Department of Semiology and Clinics, Faculty of Dentistry, University Federal of Pelotas, Pelotas
Brazil

Abstract

The present study reports a case of coronoradicular fracture with the biological width invasion that was successfully managed by orthodontic root extrusion. Clinically, the patient presented with a subgingival fracture of the first maxillary premolar, with a tooth fragment 5.0 mm below the enamel-cementum junction. The initial examination suggested a poor prognosis for the clinical case; however, we decided to employ an orthodontic root extrusion over 5 months. After 1 year, a satisfactory prosthetic rehabilitation, associated with the periodontal health, could be observed and it can be concluded that orthodontic root extrusion is an essential tool for the management of extensive subgingival fractures. Clinical Relevance to Interdisciplinary Dentistry
  • Extrusion root is a conservative treatment.
  • Root or coronal fractures can be treated with root extrusion.
  • Prognosis of this type of treatment is extremely favorable.



How to cite this article:
Martos J, de Moraes AP, Carlos CS, Nova Cruz LR, Silveira LM. Orthodontic extrusion and biologic width realignment procedures for rehabilitation in a permanent premolar with an extensive dental fracture.J Interdiscip Dentistry 2012;2:221-224


How to cite this URL:
Martos J, de Moraes AP, Carlos CS, Nova Cruz LR, Silveira LM. Orthodontic extrusion and biologic width realignment procedures for rehabilitation in a permanent premolar with an extensive dental fracture. J Interdiscip Dentistry [serial online] 2012 [cited 2021 Dec 4 ];2:221-224
Available from: https://www.jidonline.com/text.asp?2012/2/3/221/113270


Full Text

 Introduction



Frequently, we find the clinical situations with violations of the biologic width as a consequence of caries, perforations, root resorption, misplaced restorations/prosthesis, or subgingival fractures. To preserve the biologic width, a minimum of 2.0-3.0 mm of healthy supra-osseous root is necessary circumferentially. [1],[2],[3] The restitution of the biological width is not always possible without interfering negatively with the neighboring teeth. [4]

Orthodontic tooth extrusion is a minimally invasive treatment option for re-establishing biologic width and it does not affect esthetics, nor does it interfere with the periodontal support of the neighboring teeth. Several studies have reported that orthodontic extrusion may be appropriate in cases in which the loss of dental structure occurs apically to the gingival margin or bone crest. [4],[5],[6],[7],[8],[9]

The aim of this article is to describe an extrusion technique for a second permanent superior premolar with an extensive coronoradicular fracture.

 Case Report



A 24-year-old woman in good general health presented for treatment with a fractured superior second right premolar. The tooth presented an extensive subgingival fracture (5 mm) on its palatal surface [Figure 1]a and b. At the first appointment, the temporary restoration was removed for a better examination, and a periapical radiograph was taken [Figure 1]c. It was confirmed with the anamnesis data that the tooth was undergoing an endodontic treatment before fracture. After an analysis of factors, such as the patient's age, the root anatomy, and the endodontic situation and it was suggested to the patient that the tooth could be treated by means of orthodontic root extrusion to permit a confection of a single fixed crown that would result in improved esthetics and function and adequate biologic width.{Figure 1}

Orthodontic brackets were bonded to three adjacent (anchoring) teeth (23, 24, and 26) at specific heights from the tips of their cusps. A bracket was bonded on the affected teeth, placed in a more cervical position [Figure 1]d and e. The incisal aspect of the vestibular fragment was reduced to prevent occlusal interference during the extrusive movement. An orthodontic wire (twist-flex 0.5 mm) was used to produce the extrusion force. The extrusion was performed over a period of 5 months, and after realignment of the orthodontic wire, an equal period was used for stabilization [Figure 1]f.

After this period, periodontal surgery was completed to correct the gingival architecture [Figure 2]a and b. The periodontal surgery made possible the necessary endodontic retreatment. Once the endodontic retreatment was completed, the prosthetic procedures were initiated.{Figure 2}

The patient had a tooth remnant with a good substrate for prosthetic restoration, and the periodontal tissues were healthy [Figure 2]c. The procedures for prosthetic rehabilitation were initiated 90 days after periodontal surgery and initially we performed a post space preparation with a large #3 burr (Dentsply/Maillefer, Petrópolis, RJ, Brazil) by removing the quantity needed to maintain at least 4 mm of remaining of obturation material in the apical portion of the root canal, maintaining an apical seal. The root canal was isolated with vaseline using absorbent paper points and then reproduction of the internal details of the root canal was executed with DuraLay acrylic resin (Reliance Dental Mfg. Co., Worth, IL, USA). The coronal portion of the root canal was obtained directly on the remaining portion and was sent to the laboratory to obtain a cast metal post-and-core.

The cast post-and-core was fabricated in nickel chromium alloy and cemented with zinc phosphate cement (SS White Dental Products, Rio de Janeiro, RJ, Brazil), according to the manufacturer's recommendations and a prosthetic preparation was made on the premolar with a tapered, round-ended #2135 diamond burr. A provisional crown was performed and maintained for one month for accommodation and for the healing of the periodontal tissues [Figure 2]d and e.

The provisional crown was removed and a precision molding was then carried out, using additional silicone-based precision impression materials (Futura AD, DFL Ltd., Jacarepagua, RJ, Brazil). The following week, proof of coping and choice of color were performed and transfer molding was held for subsequent application of ceramics, which was later proved to be clinically evaluated, and further, some details, such as cervical adaptation, occlusal/proximal contacts, and esthetic appearance were considered adequate for their installation and definitive cementation [Figure 2]f. Four months after, the ceramic crown was placed, good esthetic appearance and functionality were observed [Figure 3]a. Radiographically, a normal aspect of the apex and osseous structures was observed [Figure 3]b.{Figure 3}

Periodontal probing 9 months after orthodontic root extrusion observed the maintenance of the periodontal health of the tissues and their adjacent sites with regard to plaque accumulation, bleeding on probing, and probing depth [Figure 3]c-f.

 Discussion



The knowledge of the biological dimensions of the periodontium led us to agree that the preservation of biologic width is fundamental to the health of the periodontal tissues, especially when the margins engage in restorative or prosthetic trespassing of those structures. [1],[2] Violation of this space will result in progressive inflammation, in which the organism, at the expense of bone resorption, promotes the reestablishment of the invaded dimensions. [3] Clinically, these changes can be observed as gingival retraction or periodontal pocket formation. [10]

Fracture of a tooth below the gingival attachment or the crest of the alveolar bone presents a very difficult restorative problem. [1] Such fractured teeth are often considered beyond hope and are extracted. The use of orthodontic extrusion, or forced eruption, has been suggested as an alternative to periodontal crown lengthening, which involves the removal of the supporting alveolar bone and can compromise esthetics. [4],[5],[6],[7],[8]

Extrusion is the easiest orthodontic movement to achieve because it closely resembles natural tooth eruption. A 3-4 mm distance from the alveolar crest to the coronal extension of the remaining tooth structure has been recommended for optimal periodontal health. [7]

The intent in the case presented was to describe an extrusion technique for a second permanent superior premolar, with an extensive coronoradicular fracture compromising the biologic width. This technique allowed for proper fabrication of a cast post-and-core and the placement of a crown on a sound tooth structure, fulfilling biologic and mechanical principles, including the ferrule effect.

 Conclusion



Within the limits of the present study, it can be concluded that orthodontic extrusion is a useful tool for the management of extensive subgingival fractures.

References

1Shenoy A, Shenoy N, Babannavar R. Periodontal considerations determining the design and location of margins in restorative dentistry. J Interdiscip Dentistry 2012;2:3-10.
2Rappelli G, Massaccesi C, Putignano A. Clinical procedures for the immediate reattachment of a tooth fragment. Dent Traumatol 2002;18:281-4.
3Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: Pulpal and restorative considerations. Dent Traumatol 2002;18:103-15.
4Farik B, Munksgaard EC, Andreasen JO, Kreiborg S. Fractured teeth bonded with dentin adhesives with and without unfilled resin. Dent Traumatol 2002;18:66-9.
5Ozel E, Karapinar-Kazandag M, Soyman M, Bayirli G. Resin composite restorations of permanent incisors with crown fractures: A case report with a six-year follow-up. Oper Dent 2011;36:112-5.
6Ozel E, Kazandag MK, Soyman M, Bayirli G. Two-year follow-up of fractured anterior teeth restored with direct composite resin: Report of three cases. Dent Traumatol 2008;24:589-92.
7Arslan H, Barutcigil Ç, Aladað H, Kürklü D. Management of fractured permanent incisors: 1 year follow-up. J Contemp Dent Pract 2011;12:501-5.
8Oliveira GM, Ritter AV. Composite resin restorations of permanent incisors with crown fractures. Pediatr Dent 2009;31:102-9.
9Dietschi D. Optimising aesthetics and facilitating clinical application of free-hand bonding using the 'natural layering concept'. Br Dent J 2008;204:181-5.
10Magne P, So WS. Optical integration of incisoproximal restorations using the natural layering concept. Quintessence Int 2008;39:633-43.