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

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Year : 2014  |  Volume : 6  |  Issue : 1  |  Page : 36-39

Multidisciplinary approach towards management of sub gingival fracture of central incisor: A clinical challenge

1 Assistant Professor, Unit of Orthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
2 Senior Residents, Unit of Endodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
3 Unit of Pedodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
4 Hindu Sevbasadan Hospital, Varanasi, Uttar Pradesh, India

Date of Web Publication18-Aug-2014

Correspondence Address:
Ashish Agrawal
Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-0754.139094

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Crown fracture accounts for the highest percentage of all traumatic injury in the permanent and deciduous dentition. Esthetic rehabilitation of crown fracture of the maxillary anterior tooth is one of the greatest challenges to the dental surgeon. The prognosis of traumatized tooth depends on accurate diagnosis and treatment procedure. This case report describes the successful endodontic management of subgingival fracture using multidisciplinary approach.

Keywords: Orthodontic extrusion, sub gingival fracture, trauma

How to cite this article:
Agrawal A, Nirula R, Gautam K, Singh R, Agrawal S. Multidisciplinary approach towards management of sub gingival fracture of central incisor: A clinical challenge. J Int Clin Dent Res Organ 2014;6:36-9

How to cite this URL:
Agrawal A, Nirula R, Gautam K, Singh R, Agrawal S. Multidisciplinary approach towards management of sub gingival fracture of central incisor: A clinical challenge. J Int Clin Dent Res Organ [serial online] 2014 [cited 2021 Jun 23];6:36-9. Available from: https://www.jicdro.org/text.asp?2014/6/1/36/139094

   Introduction Top

Trauma and accompanying fracture of permanent anterior teeth is a tragic experience for the patients and create psychological impact on them. [1] It was observed by Olsburgh et al. (2002) that depending upon the type and severity of injury, treatment of the diseased tooth may involve endodontic, restorative, orthodontic, surgical and prosthodontic procedures. [2]

Periodontal or orthodontic intervention is required to expose a sound tooth supragingival, so that a crown ferrule can be obtained. Among all the available options, orthodontic extrusion has been shown to be a better option since it does not alter the biological width and brings the gingival apparatus along with it. [3]

Villat et al. (2004) and Poi et al. (2007) stated that orthodontic extrusion is a biological way of exposure of sound tooth structure, and therefore requires a prolonged treatment. [4],[5] According to Villat et al. (2004) and Kocadereli (1998) 2-mm subgingival fracture will require an extrusion of about 4 mm. [4],[6] It is important to obtain 4 mm extrusion, so that there is a 2-mm sound supragingival tooth structure. After a latency period of few days to a few weeks, including a period of hyalinization, slow extrusion occurs at a rate of approximately 1 mm or less per week. [3]

This case report, out lines the management of subgingival fracture with multidisciplinary approach. Positive reinforcement was achieved through behavior modification, so that the patient can undergo the treatment.

Orthodontic extrusion/forced eruption and soft tissue management

The easiest way to maintain gingival esthetics is to retain a natural tooth or root, because natural teeth stimulate the body to maintain tissue and bone. Orthodontic extrusion is a common method to bring the gingival and bone level to desirable level, so as to maintain the esthetic harmony. This procedure gives clinician a method of soft- and hard-tissue augmentations. It is guided by the principles of orthodontic and bone physiology. It was first described in the literature by Heithersay [7] and Ingber. [8] Forced eruption by orthodontic forces can alter the position of gingival and the underlying crestal bone or can erupt the tooth further out of the bone. It can also be used to correct infrabony defects, reposition a gingival margin, change a root position, and to achieve a clinical crown lengthening. There are 2 types of orthodontic extrusion:

  1. Low intensity extrusion of less than 30 g of force
  2. High intensity (rapid) extrusion with forces exerted greater than 50 gm.

Low intensity orthodontic extrusion, using less than 30 g of force, can produce approximately 1.0 mm of extrusion per week. It stimulates the marginal positioning of the crestal bone and allows the gingiva to follow it. Where as a rapid extrusion will increase the tooth length, leaving its attachment apparatus behind, which is not desired in cases with subgingival fracture of tooth.

Once the orthodontic bracket has been bonded, it acts as a foreign body and does cause bacterial accumulation. Genco et al. [9] found that gingival inflammation frequently increases during orthodontic treatment. Careful examination and appointment schedule should be made for definitive periodontal therapy, which should start with scaling root planning and then re-assessing the case for hyperplastic tissue requiring surgical intervention. He advocated gingivectomy to treat hyper plastic gingival tissue. According to them, removing the irritating debris does not return the gingival to normal levels, which prevents root planning. There are different methods apart from scalpel to remove this hyperplastic tissue such as electrosurgical treatment and lasers.

   Case report Top

A 25-year-old female patient reported to Department of Conservative Dentistry and Endodontics with a fracture of tooth right maxillary central incisor due to fall from stairs. On clinical examination, the fracture line was oblique. The fracture line extended 0.5 mm supragingival on the labial surface, and 0.5 mm subgingival on the proximal and palatal aspect. Radiographic examination revealed a horizontal tooth fracture of upper right central incisor below cervical level [Figure 1]. A definitive multidisciplinary treatment plan was formulated, which included endodontic treatment (RCT followed by post and core), orthodontic extrusion, periodontic therapy (gingivectomy) and prosthodontic rehabilitation of the diseased tooth (metal ceramic crown). The treatment planned was explained and proper informed consent was taken from the patient.
Figure 1: (a) Pre treatment X-ray showing subgingival level of fracture (b) X-ray for Fiber post inserted after RCT (c) 016 NITI engaged to the bonded lingual button

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Root canal treatment (RCT) was done immediately to relieve the patient from pain. With a rubber dam in place and after access opening, root canal instrumentation was performed using a crown-down technique. The working length was established at 1 mm short of the radiographic apex. Copious irrigation with 2.5% sodium hypochlorite was done throughout cleaning and shaping procedures. Sectional method of obturation was done with gutta-percha and AH Plus (Dentsply) sealer was used. Fiber post-space was prepared. Dual cure resin (LuxaCore® Dual, DMG America) was used to bond the fiber, post firmly in the prepaired post-space [Figure 1]a.

The core build up was done with Luxacure Duo dual cure resin cement. The root apex was fully formed. Since the root length was sufficient, orthodontic extrusion was planned. Extrusion of the root by 2 mm maintained the crown root favorable ratio.

Once the core was build, a lingual button was bonded on the core [Figure 1]b and [Figure 2]. The orthodontic extrusion was initiated using Beggs' bracket. There was a modification done in bracket placement. The bracket was placed upside down for the ease of wire engagement. This was also done in order to prevent any unwanted extrusion of adjacent teeth; therefore, the upper right lateral incisor was not legated to the main archwire. The archwire 016 NITI was loosely engaged in the brackets and tightly legated to the lingual button. The patient was kept on a recall visit of one-month duration.
Figure 2: (a) Lingual button bonded on the core (b) Intra oral view after two months (c) Gingival attachment brought along extrusion (d) Gingivectomy followed by core modification for PFM crown (e) Occlusal clearance after crown cutting

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The desired extrusion was achieved within 2 months, which is physiologically desirable [Figure 2]a. Extrusion of teeth was accompanied by growth of supporting structure i.e. Bone and gingiva. As a result, Gingiva margin on 11 was more incisal than 21 [Figure 2]b. Once the orthodontic treatment was done and braces were removed, patient was recalled after 48 hours for periodontal checkup. The gingival condition of the patient was both hyperplastic and edematous. The gingival edema or hypertrophy was treated by scaling and root planning procedures. To further review the gingival health, the patient was recalled after two weeks. Significant amount of edema resolved bringing the gingival tissue to a relatively healthier state. Since the esthetics was prime concern for the young girl patient, gingivectomy was performed in order to remove the hyperplastic gingival tissue. Care was taken that the attachment apparatus was not severed [Figure 2]c. Gingivectomy procedure at an early stage would have caused a violation of biological width. Once hemostatsis was achieved, the core was modified for all ceramic crown [Figure 2]d. All ceramic crown was fabricated and luted using resin modified GIC (3M) [Figure 3]a and b.
Figure 3: (a) Post-treatment of intra oral photo (b) Extra - Oral post-treatment one year follow-up

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   Discussion Top

Esthetic rehabilitation of crown fracture of the maxillary anterior tooth is one of the greatest challenges to the dental surgeon. Crown fracture has been documented to account for up to 92% of all traumatic injuries to the permanent dentition. The number and extent of tissue involvement in the traumatic injury determines the management needs. Several factors influence the management of crown fracture as advocated by Reis et al. (2001) and Anderson et al. (1995), which includes extent of fracture, pattern of fracture and restorability of fractured tooth, secondary trauma injuries, presence or absence of fractured tooth fragment and its condition, occlusion, esthetics, finances, and prognosis. [10],[11] They also suggested that orthodontic extrusion should be accompanied with crown lengthening procedure that involves the removal of supporting alveolar bone for management of subgingival fracture of crown of single-rooted tooth. The average biologic width is 2.04 mm; it comprises of gingival connective tissue and epithelial attachment in the form of the functional epithelium. 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. Reis et al. (2004) suggested that the distance from the alveolar crest to the coronal extent of the remaining tooth structure should be at least 3-4 mm, and if it is less, a risk of impinging upon the functional epithelium and connective tissue attachment in a subgingival preparation is obvious. [12]

Johnson and Silvers (1986) observed, after the extrusion, the gingival margin had migrated coronally. [13] Gingival re-contouring was done to reposition the gingival margin in line with the contra-lateral tooth for good esthetics as advocated by King and So (1998). [14] A circumferential supracrestal fibrotomy was also performed to prevent intrusion to the earlier position as done by King, So (1998) and Arhun et al. (2006). [14],[15]

Extrusion was done to get 2 mm supragingival tooth structure so that a circumferential core ferrule and crown ferrule of 1 mm each is available, which is mandatory for proper stress distribution and failure of restoration.

Thus, in this case, apart from achieving the goal of extrusion for crown ferrule and long-term restorative success, we have tried to achieve esthetics during the course of treatment.

   Conclusion Top

A multidisciplinary approach is necessary for the restoration of tooth fractured at subgingival level, because the margin of restoration should ideally be supragingival. A definite treatment protocol should be followed to restore fractured anterior teeth functionally and esthetically. Light orthodontic force with the help of fixed orthodontic therapy is a potential option for extrusion of tooth. This case report described one such case report with desirable outcome.

   References Top

1.Cortes MI, Marcenes W, Sheiham A. Impact of traumatic injuries to the permanent teeth on the oral health-related quality of life in 12-14-year-old children. Community Dent Oral Epidemiol 2002;30:193-8.  Back to cited text no. 1
2.Olsburgh S, Jacoby T, Krejci I. Crown fracture in the permanent dentition: Pulpal and restorative considerations. Dent Traumatol 2002;18:103-15.   Back to cited text no. 2
3.Minsk L. Orthodontic tooth extrusion as an adjunct to periodontal therapy. Compend Contin Educ Dent 2000;21:768-70, 772, 774.  Back to cited text no. 3
4.Villat C, Machtou P, Naulin-Ifi C. Multidisciplinary approach to the immediate esthetic repair and long-term treatment of an oblique crown-root fracture. Dent Traumatol 2004;20:56-60.   Back to cited text no. 4
5.Poi WR, Cardoso Lde C, de Castro JC, Cintra LT, Gulinelli JL, de Lazari JA. Multidisciplinary treatment approach for crown fracture and crown-root fracture: A case report. Dent Traumatol 2007;23:51-5.   Back to cited text no. 5
6.Kocadereli I, Tasman F, Guner SB. Combined endodontic - orthodontic and prosthodontic treatment of fractured teeth. Case report. Aust Dent J 1998;43:28-31.   Back to cited text no. 6
7.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. 7
8.Ingber JS. Forced eruption. I. A method of treating isolated one and two wall infrabony osseous defects-rationale and case report. J Periodontol 1974;45:199-206.  Back to cited text no. 8
9.Genco R, Goldman H, Cohen D. Contemporary Periodontics. St Louis: CV Mosby; 1990.  Back to cited text no. 9
10.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. 10
11.Andreasen FM, Norén JG, Andreasen JO, Engelhardtsen S, Lindh-Strömberg U. Long term survival of fragment bonding in the treatment of fractured crowns: A multicenter clinical study. Quintessence Int 1995;26:669-81.  Back to cited text no. 11
12.Reis A, Loguercio AD, Kraul A, Matson E. Reattachment of fractured teeth: A review of literature regarding techniques and materials. Oper Dent 2004;29:226-33.  Back to cited text no. 12
13.Johnson GK, Sivers JE. Forced eruption in crown-lengthening procedures. J Prosthet Dent 1986;56:424-7.  Back to cited text no. 13
14.King NM, So L. A laboratory fabricated fixed appliance for extruding anterior teeth with subgingival fractures. Pediatr Dent 1988;10:108-10.   Back to cited text no. 14
15.Arhun N, Arman A, Ungor M, Erkut S. A conservative multidisciplinary approach for improved aesthetic results with traumatized anterior teeth. Br Dent J 2006;20:509-12.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]


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