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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 122-125

Multidisciplinary treatment of a fractured maxillary central incisor


1 Department of Orthodontics, Kamineni Institute of Dental Sciences, Narketpally, Telangana, India
2 Department of Conservative Dentistry and Endodontics, Kamineni Institute of Dental Sciences, Narketpally, Telangana, India

Date of Web Publication26-May-2017

Correspondence Address:
Praveen Kumar Neela
Department of Orthodontics, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda - 508 254, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_20_17

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  Abstract 

Subgingivally fractured incisors are still a challenge to treat. Restoration of severely damaged teeth requires careful attention and comprehensive preplanned treatment. Here, a patient who had traumatic injury to the upper left central incisor which led to an oblique fracture involving enamel, dental and extending into the root below the gingival margin was saved from extraction by accelerated forced eruption of a root portion, allowing placement of crown, and eliminating the need for a fixed partial denture. A tooth otherwise would have gone for extraction routinely was thus saved and restored through a multidisciplinary approach by a combined orthodontic, periodontal and endodontic treatment.

Keywords: Crown-root fracture, extrusion, forced eruption, multidisciplinary treatment


How to cite this article:
Neela PK, Sesham VM, Mamillapalli PK, Vemisetty HK. Multidisciplinary treatment of a fractured maxillary central incisor. Indian J Dent Sci 2017;9:122-5

How to cite this URL:
Neela PK, Sesham VM, Mamillapalli PK, Vemisetty HK. Multidisciplinary treatment of a fractured maxillary central incisor. Indian J Dent Sci [serial online] 2017 [cited 2019 Sep 17];9:122-5. Available from: http://www.ijds.in/text.asp?2017/9/2/122/207103


  Introduction Top


Many teeth are extracted because traumatic or pathologic conditions affect the cervical third of the root. These conditions render the tooth unrestorable or extremely difficult to restore.[1],[2] Such teeth are often considered hopeless and are thus extracted.

Crown lengthening procedures are attempted in some cases. The use of orthodontic extrusion, also referred to as forced eruption, has been suggested as an alternative to periodontal crown lengthening which involves the removal of supporting alveolar bone and can compromise esthetics.[3],[4],[5],[6],[7] It is best in case of horizontal fractures.

However, oblique directional fractures still require crown lengthening procedures as orthodontic extrusion on one side does not match with the other side. Regaining adequate biologic dimension for prosthetic restorations sometimes require the combined expertise of an orthodontist, a periodontist, and a restorative dentist.


  Case Report Top


A 21-year-old boy presented for treatment with the main complaint of a mobile anterior tooth.

The patient's medical and family histories were not relevant. The intra-oral examination revealed a discolored maxillary left central incisor with an excessively mobile crown. The tooth had an oblique fracture involving enamel, dentin, and extending into the root below the gingival margin and showed signs of previous endodontic therapy [Figure 1]. The adjacent incisors presented physiologic mobility and responded positively to the electric pulp tester.
Figure 1: Fractured left central incisor.

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Dental history

The dental history recorded in the patient's file revealed a previous trauma 4 years before. The maxillary left central incisor had sustained an uncomplicated coronal fracture involving enamel and dentin extending into the root below the gingival margin in an oblique direction. It was attached and root canal treatment was done.

Radiographic findings

A periapical radiograph of the permanent incisors revealed that the left central incisor was endodontically treated, obturated, and had sustained a fracture at the level of the cementoenamel junction extending 4–5 mm below the gingival margin [Figure 2].
Figure 2: Intraoral – periapical showing fractured central incisor.

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Treatment plan

A multidisciplinary approach was finalized involving orthodontic, endodontic, and periodontal treatment.

Treatment proper

After dental prophylaxis and oral hygiene education, the mobile crown was firmly attached to the root portion by glass ionomer cement [Figure 3]. The orthodontic treatment comprised forced eruption of the root of the fractured maxillary left central incisor along with attached crown portion.
Figure 3: Mobile crown firmly attached to the root portion by glass ionomer cement.

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Banding of left central incisor (21) was done, onto which a round molar tube is welded. Remaining anterior teeth were bonded using Begg brackets [Figure 4]. A round molar tube was welded instead of a Begg bracket as it will give efficient and effective extrusion of the tooth. Remaining anterior teeth were stabilized by 0.020” round SS wire which were piggybacked by 0.014” round NiTi wire which passed through round molar tube [Figure 5]. The patient was examined every 3 weeks to check the amount of extrusion clinically.
Figure 4: Begg brackets bonded to anterior teeth except 21 which is banded.

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Figure 5: Anterior teeth stabilized by 0.020“ round SS wire, piggybacked by 0.014” round NiTi wire.

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After 1 month of extrusion, NiTi wire is passed over the molar tube instead of passing through the tube and 0.020” SS with a vertical step bend in the region of 21 to enable further extrusion [Figure 6]. Eight weeks after orthodontic treatment, there was clear evidence both clinically [Figure 7] and radiographically. [Figure 8] shows the preextrusion intraoral periapical (IOPA) radiograph and postextrusion IOPA radiograph revealing evidence of 4 mm extrusion. Active treatment was followed by 10 weeks of retention with the same appliance.
Figure 6: One month after extrusion.

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Figure 7: After 4 mm of extrusions.

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Figure 8: Preextrusion intraoral periapical and postextrusion intraoral periapical.

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There were no complications during or after the orthodontic treatment. After the retention period, coronal portion of the fractured crown was removed and periodontal procedure of crown lengthening, gingival contouring, and circumferential fiberotomy around the extruded tooth was done [Figure 9]. Later, a fiber post core preparation was done [Figure 10].
Figure 9: After crown lengthening.

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Figure 10: After post and core placement.

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As there was a mild spacing in the upper anterior region, composite restoration was done for 11, 12, and 22. Finally, the extruded tooth was successfully restored with a ceramic crown constructed over the postcore. The ceramic crown had gingival porcelain at the gingival margin of the crown to improve the esthetics [Figure 11] and [Figure 12].
Figure 11: Posttreatment intraoral photograph.

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Figure 12: Posttreatment extraoral photograph.

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  Discussion Top


The necessity for an interdisciplinary approach to treat routine dental problems has been recognized for a long time. In many cases of fractured crown and root fracture, forced orthodontic eruption provides a useful alternative to extraction and placement of implant or fixed partial denture. Adjacent teeth need not be prepared for fixed prostheses and alveolar bone is conserved.

Reattachment of the fractured crown fragment followed by orthodontic extrusion was done before the final postendodontic restoration. In this case, reattachment of the fragment served as a provisional restoration during orthodontic extrusion. Original crown fragment instead of temporary resin crown restoration was used as the technique faster, economical as it saves laboratory time and cost, and more esthetic as it restores the original color and contour of the tooth.

Movement of the tooth by extrusion involves applying traction forces in all regions of periodontal ligament to stimulate marginal apposition of crestal bone. When stronger traction forces are applied, as in rapid extrusion, coronal migration of tissues supporting the tooth is less pronounced because rapid extrusion exceeds the capacity for physiologic adaptation.

In this case, round molar tube welded onto the left central incisor band for effective extrusion and remaining anterior teeth were stabilized by round SS wire to prevent unwanted effects during extrusion. The band material was wrapped and cemented around the fractured left central incisor as gingivally as possible for two reasons. One, for effective extrusion when super elastic nickel–titanium wire was passed and two, to hold the crown root fracture as a single unit.

Rapid extrusion involves stretching and readjusting of periodontal fibers, thereby avoiding marked bone remodeling by virtue of rapid movement. Since there was no coronal shift of the alveolar bone, no bone reshaping was required before coronal restoration. Coronal shift of the marginal gingiva was observed as it was a proliferation of gingival tissue due to rapid extrusion and was treated by gingival contouring and circumferential fiberotomy around the extruded tooth. This will reduce relapse tendencies.

The present case report highlights the importance of multidisciplinary approach in dealing fractured teeth by forced orthodontic extrusion and placement of post and core followed by prosthesis, thus saving a tooth from being extracted.


  Conclusion Top


The present case report demonstrates the importance of multidisciplinary approach by involving orthodontist, endodontist, and periodontist for the successful management of a subgingivally fractured central incisor.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank Dr. Satyanarayana, professor, department of periodontics for his contribution in the periodontal aspect of the treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ingber JS. Forced eruption: Part II. A method of treating nonrestorable teeth – Periodontal and restorative considerations. J Periodontol 1976;47:203-16.  Back to cited text no. 1
[PUBMED]    
2.
Delivanis P, Delivanis H, Kuftinec MM. Endodontic-orthodontic management of fractured anterior teeth. J Am Dent Assoc 1978;97:483-5.  Back to cited text no. 2
    
3.
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. 3
    
4.
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. 4
    
5.
Biggerstaff RH, Sinks JH, Carazola JL. Orthodontic extrusion and biologic width realignment procedures: Methods for reclaiming nonrestorable teeth. J Am Dent Assoc 1986;112:345-8.  Back to cited text no. 5
    
6.
Johnson RH. Lengthening clinical crowns. J Am Dent Assoc 1990;121:473-6.  Back to cited text no. 6
    
7.
Baker IM. Esthetic extrusion of a nonrestorable tooth. J Clin Orthod 1990;24:323-5.  Back to cited text no. 7
    


    Figures

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



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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