JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2019  |  Volume : 11  |  Issue : 2  |  Page : 101-105

Management of subgingival fractured tooth

1 Department of Conservative Dentistry and Endodontics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Orthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Conservative Dentistry and Endodontics, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar, India

Date of Submission07-Jun-2019
Date of Acceptance03-Aug-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Nidhi Singh
321, Vikas Nagar (Parahupur), Mughalsarai, Chandauli - 232 101, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_17_19

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Traumatized anterior teeth along with subgingival crown fractures are challenge to treat. Management of subgingival fractures includes exposing the cervical margin, above the gingiva followed by appropriate coronal restoration. The treatment modalities, which involve exposing the cervical margin, are surgical crown lengthening or by orthodontic extrusion. Orthodontic extrusion of subgingival fractured maxillary anterior tooth was done in this case report after endodontic treatment followed by esthetic rehabilitation which was yet conservative and cost – effective.

Keywords: Biological width, fiberotomy, gingivectomy, orthodontic extrusion, prosthetic rehabilitation, subgingival root fracture

How to cite this article:
Singh N, Chaturvedi T P, Wang CK. Management of subgingival fractured tooth. J Int Clin Dent Res Organ 2019;11:101-5

How to cite this URL:
Singh N, Chaturvedi T P, Wang CK. Management of subgingival fractured tooth. J Int Clin Dent Res Organ [serial online] 2019 [cited 2020 Mar 31];11:101-5. Available from: http://www.jicdro.org/text.asp?2019/11/2/101/273757

   Introduction Top

Fracture in the anterior teeth is one of the common findings in dental clinics due to trauma, which is maximum seen in both young and adult patients. Tooth fracture is considered as the third most common cause of tooth loss.[1] Today scenario is the replacement of a nonrestorable tooth with an implant; it is not a complication-free procedure. Efforts must be taken to avoid tooth loss and to restore form and function, paying special respect to the gingival portion of the attachment apparatus.

In situations in which the biologic width has been compromised, there is solution of surgical approach, a clinical crown lengthening procedure sacrificing supporting bone of the tooth and its neighbors. However, forced eruption is an alternative treatment, which was introduced in 1973 by Heithersay GS.[2] Orthodontic forced eruption is a suitable approach to tooth fracture below the gingival attachment or alveolar bone crest. Subsequent to endodontic and orthodontic treatment, prosthodontic rehabilitation is also done.

Orthodontic extrusion is a conservative, simple technique for the restoration of teeth without sacrificing the supporting periodontal ligament and bone. It provides sound margins for proper finish line so that prosthesis can be prepared and the esthetic appearance of the tooth is also maintained without any negative change in the length of the clinical crowns.[3] The present article discusses the two case reports in the management of subgingival tooth fractures. The article also emphasizes the importance of orthodontic extrusion in such treatment approaches so as to restore and rehabilitate the tooth functionally and esthetically.

   Case Reports Top

Case 1

A male patient aged 35 years reported to the department of conservative dentistry and endodontics with the chief complaint of fractured upper left front tooth 2 days back. He gave a history of trauma with a moderate type of pain which was continuous; pain aggravated on touch and was relieved on taking medication. The patient showed no other signs of lacerations in the adjacent hard and soft tissue. Intraoral examination revealed a chisel type fracture of tooth 21 [Figure 1]a. Fracture line was extending subgingivally on the palatal aspect [Figure 1]b. On radiological examination, the remaining roots appeared to have sufficient length and width and taper without any fracture and could be considered for extrusion [Figure 1]c. Hence, the diagnosis was the symptomatic apical periodontitis with Ellis class III fracture in relation to 21 and endodontic treatment was done [Figure 2]. After that, orthodontic extrusion was started to move the fracture line supragingivally. Extrusion was done with the help of fixed orthodontic appliance (0.018-inch MBT brackets) bonded to six anterior teeth. 016-inch nickel-titanium (NiTi) wire was used to extrude the incisor. Fractured tooth segment was prepared to fit the fracture line and to provide retention from the intracanal walls [Figure 3]a. A 21-gauge orthodontic straight wire was bonded to fracture segment using composite resin [Figure 3]b and then luted to fractured tooth using dual-cure composite resin [Figure 3]c. The bracket on the target tooth was positioned more apically than the brackets on the adjacent teeth. Anterior six teeth were bonded and 016 NiTi wire was placed and ligated with ligature wire [Figure 4]. The patient was kept on follow up twice in a week. Amount of extrusion was gained after 14 days [Figure 5]. The incisal and palatal aspects of the provisional restoration were reduced to prevent occlusal interferences during extrusive movement. Gingivectomy was done to maintain the gingival contour and fibrotomy of the stretched periodontal fibers was performed to avoid relapse after extrusion [Figure 6]. This allows the fibers to heal and reorganize in the new position of the root. After that, bracket on the target tooth was re-positioned more apically and recalled the patient after 14 days. By considering the estimated crown-root ratio and the extension of the fracture, 3–4 mm extrusion was obtained as adequate to provide sufficient biologic width as well as to provide a ferrule for the final restoration.
Figure 1: (a) labial view photograph showing more than half-crown structure lost, after removal of fracture segment, (b) lingual view photograph showing fractured line extends to the sub-gingival margin, (c) preoperative radiograph

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Figure 2: obturation was done

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Figure 3: (a) fractured tooth segment, (b)orthodontic wire bonded to fractured segment, (c) luted with dual-cure resin

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Figure 4: anterior six teeth bonded, 016 nickel-titanium wire placed and ligated with ligature wire

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Figure 5: amount of extrusion after 14 days

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Figure 6: surgical No. 12 blade was used to contour gingiva

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After attaining a final position, this position was to maintain for 4 weeks without stretching it, i.e., no active force was applied. Passive phase was necessary to avoid relapse. Following the retentive phase, during which tooth stability was gained, the provisional crown was removed [Figure 7]a. Palatally sufficient amount of biological width was obtained [Figure 7]b. Post and core was done, crown was prepared, and retraction cord was applied [Figure 8]. Shade matching was done [Figure 9]. After impression taken, the provisional acrylic resin restoration was then readapted on prepared sound tooth margins to prevent any change in tooth position. Four weeks later, a porcelain-fused-to-metal crown was fabricated and delivered [Figure 10].
Figure 7: (a) provisional crown was removed (labial view), (b) postoperative after extrusion (palatal view)

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Figure 8: crown preparation was done

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Figure 9: shade matching was done

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Figure 10: final fitting of porcelain fused metal

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Case 2

A female patient aged 29 years reported to the department with the chief complaint of pain and swelling in the upper right and left front teeth region for 4–5 days. She gave a history of trauma with a sharp and intermittent pain which was relieved on taking medication. On clinical examination, two-thirds of the coronal tooth structure of the right central incisor was fractured and the fracture line was below the gingival margin on the palatal side [Figure 11]. The left central incisor was also fractured at incisal one third. Diagnostic intraoral periapical (IOPA) X-ray of 11 and 21 showed closed root apex, and there was no sign of root fracture. Slight intrusion of 11 was observed in IOPA X-ray. Hence, the diagnosis was symptomatic apical periodontitis in relation to 11 and 21. The same procedure was repeated, i.e., root canal treatment was completed, and then, fixed orthodontic extrusion was done. In the present case, sufficient amount of extrusion was obtained in 14 days [Figure 12]. Core was build up with composite resin and splinting wire positioned for 2 weeks [Figure 13].
Figure 11: preoperative photograph

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Figure 12: postoperative photograph after extrusion

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Figure 13: core was build up with composite resin

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   Discussion Top

Tooth fracture may leave either subgingival margin or subcrestal margin, which leads to unsuitable for restoration of the remaining tooth. Because of subgingival or subcrestal margin fractures, the remaining root for restoration will impinge on the biological width. The biological width is achieved by orthodontic extrusion and gets sufficient supragingival tooth tissue. It is indicated in all cases where defect is subcrestal such as fractures, perforations, or caries.[4],[5]

In the present cases, extrusion was done with fixed appliances, for orthodontic forced eruption after endodontic treatment. Surgical reposition is also the choice of treatment; however, due to this, there is increase possibility of external root resorption and loss of bone support.[6] Malmgren et al. also suggested that there were more chances of resorption of the root in traumatized teeth than uninjured teeth.[7] In 1985, Andreasen and Pedersen reported that extrusion was done by fixed or removable appliances and by fixed appliance extrusion is fast as compared to removable appliance.[8]

In present first case, active orthodontic treatment was followed out for 28 days, and in second case, it was followed out for14 days. With the help of fixed appliances, sound tissue margin and adequate biological width were obtained for restoration. After sufficient extrusion, a fibrotomy of the stretched periodontal fibers is usually done to avoid relapse. Forced eruption combined with fibrotomy allows the fibers to heal and reorganize in the new position of the root.[9],[10] It should be stabilized for 8–12 weeks before the fabrication of a permanent post and core.[4]

Successful resistance form of a fractured tooth depends on adequate ferrule. Ferrule is a band of extracoronal material at the cervical margin of a crown preparation that encompasses the teeth and obtains by the crown that is placed over the post and core system. Research has shown that 1–1.5 mm of ferrule is required for adequate fatigue resistance for restoration.[11] A crown-root ratio must be obtained approximately 1:1 for a successful posttreatment restoration.

   Conclusion Top

Orthodontic extrusion of traumatized incisor teeth is successful in the management of subgingivally fractured teeth. It gives us better chance to solve the problem of subgingival fractured teeth with a conservative and minimal traumatized approach, so as to restore and rehabilitate the tooth functionally and esthetically.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Andreasen FM, Andreasen JO, Cvek M. Root fractures. In: Andreasen FM, Andreasen JO, editors. Textbook and Color Atlas of Traumatic Injuries to Teeth. Copenhagen: Blackwell Publishing Ltd.; 2007. p. 337-71.  Back to cited text no. 1
Heithersay GS. Combined endodontic-orthodontic treatment of transverse root fractures in the region of the alveolar crest. Oral Surg Oral Med Oral Pathol 1973;36:404-15.  Back to cited text no. 2
Smidt A, Lachish-Tandlich M, Venezia E. Orthodontic extrusion of an extensively broken down anterior tooth: A clinical report. Quintessence Int 2005;36:89-95.  Back to cited text no. 3
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
Cronin RJ, Wardle WL. Prosthodontic management of vertical root extrusion. J Prosthet Dent 1981;46:498-504.  Back to cited text no. 5
Andersson L, Blomlöf L, Lindskog S, Feiglin B, Hammarström L. Tooth ankylosis. Clinical, radiographic and histological assessments. Int J Oral Surg 1984;13:423-31.  Back to cited text no. 6
Malmgren O, Goldson L, Hill C, Orwin A, Petrini L, Lundberg M. Root resorption after orthodontic treatment of traumatized teeth. Am J Orthod 1982;82:487-91.  Back to cited text no. 7
Andreasen FM, Pedersen BV. Prognosis of luxated permanent teeth – The development of pulp necrosis. Endod Dent Traumatol 1985;1:207-20.  Back to cited text no. 8
Malmgren O, Malmgren B, Goldson L. Orthodontic management of the traumatized dentition. In: Andreasen JO, Andreasen FM, editors. Text Book and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. Copenhagen, Munksgaard: Denmark; 1994. p. 600-33.  Back to cited text no. 9
Jacobs SG. The treatment of traumatized permanent anterior teeth: Case report and literature review. Part I – Management of intruded incisors. Aust Orthod J 1995;13:213-8.  Back to cited text no. 10
Libman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodont 1995;8:155-61.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]


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