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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2006  |  Volume : 24  |  Issue : 4  |  Page : 197-200
 

A multi-disciplinary approach in the management of a traumatized tooth with complicated crown-root fracture: A case report


1 Department of Conservative Dentistry Endodontics, Rural Dental College, Loni, Maharashtra, India
2 Department of Pedodontics, Rural Dental College, Loni, Maharashtra, India

Correspondence Address:
C B Heda
Department of Pedodontics, Rural Dental College, PIMS, Loni - 413 736, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.28077

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   Abstract 

A 13-year-old boy had fractured his maxillary right central incisor. The fracture line involved 2/3rd of the crown, compromising the pulp and extended subgingivally on the palatal aspect invading the biologic width. The procedure used to manage this case included endodontic treatment of residual tooth orthodontic extrusion to move the fracture line above the alveolar bone. Finally the tooth was restored prosthodontically.


Keywords: Biologic width, orthodontic extrusion, crown-root fracture


How to cite this article:
Heda C B, Heda A A, Kulkarni S S. A multi-disciplinary approach in the management of a traumatized tooth with complicated crown-root fracture: A case report. J Indian Soc Pedod Prev Dent 2006;24:197-200

How to cite this URL:
Heda C B, Heda A A, Kulkarni S S. A multi-disciplinary approach in the management of a traumatized tooth with complicated crown-root fracture: A case report. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2019 Nov 13];24:197-200. Available from: http://www.jisppd.com/text.asp?2006/24/4/197/28077



   Introduction Top


Trauma with accompanying fracture of a permanent incisor is a tragic experience for the young patient and creates psychological impact on both the parents and children. If the injury involves the loss of extensive tooth structure, it alters the child's appearance and makes him the target for teasing and ridicule by other children.

This case report outlines the management of complicated crown-root fracture N873.64 [Andreasen modification of WHO classification, 1981][1] and Type B fracture [Dean's classification][2] with maintaining the healthy periodontal tissue and alveolar bone.


   Case Report Top


A 13 year old boy reported with a complain of pain and mobility with upper anterior teeth and with a history of roadside injury 14 h before. Clinical examination revealed oblique fracture line on tooth no. 11, 1 mm supragingivally on the labial aspect and extending palatally towards the coronal third of root. The tooth was tender and the fractured coronal segment was mobile. It was attached only by periodontal ligament fibers on palatal side. The gingiva around the fractured tooth was inflamed on palatal aspect. Radiographic examination confirmed the findings of the clinical examination; the fracture line on palatal side could be traced 2 mm below the alveolar crest. Periapical view showed closed apex with tooth no. 11. The periodontal space around the tooth was widened. There was no damage to adjacent teeth [Figure - 1].

On the basis of clinical and radiographic findings, a diagnosis of complicated crown-root oblique fracture, Dean's type B [plane of fracture angled cervically in a facial-to-lingual direction when viewed proximally] was made [Figure - 2].

A definitive treatment plan was made as follows - removal of fractured fragment under local anesthesia followed by endodontic therapy of residual tooth. After this orthodontic extrusion to move the fracture line 3 mm above the alveolar crest was planned to regain the lost biologic width.

The loose fragment of crown was removed under local anesthesia and root canal therapy of residual tooth was performed. The canal was obturated using lateral condensation gutta percha technique and a post space was prepared [Figure - 3].

A 'J' shaped post hook was cemented with zinc phosphate cement. A horizontal wire was attached to adjacent teeth at desired position by composite resin. The distance between the end of post and arch wire was adjusted to 3 mm. Extrusion was activated by an elastic E-chain which was put around the horizontal wire and the 'J' hook [Figure - 4][Figure - 5].

One week later there was 1 mm of extrusion [Figure - 6] but the tooth was moving labially so the horizontal wire was changed with a new horizontal wire having a bend to cross midline of tooth no. 11 [Figure - 7].

At the end of 3 weeks the hook was in contact with the horizontal wire and fracture line on palatal aspect could be seen [Figure - 8][Figure - 9][Figure - 10]. At this stage, circumferential supracrestal fibrotomy was performed for prevention of relapse.[3] It was now stabilized for 8 weeks[4] by ligating the 'J' hook and horizontal wire with ligature wire [Figure - 11].

At the end of 4 weeks, circumferential supracrestal fibrotomy was reapeated. The bony and periodontal repair was evident within 8 weeks. After 8 weeks, the horizontal wire and J hook were removed and a fiber-optic post [Luscent Anchor, Dentatus] was cemented with dual cure composite resin cement and a core was built up with composite resin [Figure - 12][Figure - 13][Figure - 14].

Finally the tooth was restored prosthodontically for good esthetic results.


   Discussion Top


There are several options for the treatment of tooth fracture involving the biologic width which include:

  • Tooth extrusion
  • Fragment reattachment only
  • Fragment reattachment or reconstruction after crown lengthening
  • Tooth extraction in severe case.


Tooth restored with adhesive reattachment cannot withstand functional and orthodontic forces until prosthetic rehabilitation is performed; hence it cannot be considered a durable treatment.[5]

In the present situation, the subgingival location of the fracture line could not allow an optimal sealing besides oral hygiene could have been difficult to maintain.

In such a case, two main factors must be addressed:

  • the fracture margin access and
  • the possibility of performing a tight seal restoration.[6]


An orthodontic extrusion of fractured tooth will maintain the periodontal tissues at the same level and restore a physiological attachment. 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] This treatment is preferred over crown lengthening which removes alveolar bone and may become the reason for pocket formation. The orthodontic procedure allows the movement of the fracture line supragingivally and then optimizes the marginal sealing. The forced eruption was limited to 3 mm (it should be maximum 5 mm as suggested by Ingle)[4] and was achieved with minimal force (Only 0.2 - 0.3 N).[7]

The major limitation of this treatment is the longer duration of treatment and a longer stabilization period. It may also impair good esthetic resolution because the cervical diameter of extruded tooth is smaller than the adjacent teeth.[8]

When the tooth is moved to the new position, the supracrestal gingival fibers tend to stretch and may become the major cause of relapse. A circumferential suprecrestal fibrotomy was performed to avoid such an occurrence when the tooth was in new corrected position.

Finally, the use of a fiber-optic post gives good esthetic results and increases retention and distributes the stresses along the root.[6]


   Conclusion Top


Restoration of traumatized teeth requires a close collaboration between the different dental fields to avoid loss of tooth. Even though orthodontic extrusion reduces crown/root ratio and widens the embrasure, this approach allows to maintain the biologic width and optimizes the marginal sealing.[6]

The present case reports a multidisciplinary management of a dental trauma that leads to conservation of a tooth and its permanent restoration. In addition, the adjacent teeth need not be prepared for fixed prosthesis and the alveolar bone is conserved.

 
   References Top

1.Rao A. Principles and practice of pedodontics. 1st ed. Jaypee Brothers Medical Publishers (P) Ltd: New Delhi; 2006.  Back to cited text no. 1    
2.Trushkowsky RD. Esthetic, biologic and restorative considerations in coronal segment reattachment for a fractured tooth: zA clinical report. J Prosthet Dent 1998;79:115-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Carranza FA, Newman MG. Clinical periodontology. 8th ed. A Harcourt Publishers International Company.  Back to cited text no. 3    
4.Ingle JI, Bakland LK. Endodontics 5th ed. BC Decker Inc.   Back to cited text no. 4    
5.Cengiz SB, Kocadereli I, Gungor HC, Altay N. Adhesive fragment reattachment after orthodontic extrusion: A case report. Dent Traumatol 2005;21:60-4.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.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. 6  [PUBMED]  [FULLTEXT]
7.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. 7    
8.Nogueira Filho Gda R, Machion L, Teixeira F B, Pimenta LA, Sallum EA. Reattachment of an autogenous tooth fragment in a fracture with biologic width violation: A case report. Quitessence Int 2002;33:181-4.  Back to cited text no. 8    


    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], [Figure - 13], [Figure - 14]


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    Abstract
    Introduction
    Case Report
    Discussion
    Conclusion
    References
    Article Figures

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