Year : 2010 | Volume
: 28 | Issue : 1 | Page : 34--37
Treatment of crown dilaceration: An interdisciplinary approach
P Subramaniam1, P Naidu2,
1 Professor and Head of the Department, The Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Center, Bommanahalli, Bangalore, India
2 Post Graduate Student, The Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Center, Bommanahalli, Bangalore, India
The Oxford Dental College, Hospital and Research Center, Bommanahalli, Bangalore
Trauma to primary teeth can result in a wide range of disturbances to the underlying permanent teeth, such as dilaceration. Root dilacerations occur more commonly than crown dilacerations. This paper is a report of an 11-year-old girl with a missing maxillary left anterior tooth. Past history revealed premature loss of primary maxillary anterior teeth due to trauma. Radiographic examination revealed crown dilaceration of permanent maxillary left central incisor. An interdisciplinary approach in the management of this child is presented herewith.
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Subramaniam P, Naidu P. Treatment of crown dilaceration: An interdisciplinary approach.J Indian Soc Pedod Prev Dent 2010;28:34-37
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Subramaniam P, Naidu P. Treatment of crown dilaceration: An interdisciplinary approach. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2021 May 8 ];28:34-37
Available from: https://www.jisppd.com/text.asp?2010/28/1/34/60479
Injuries to the primary dentition are among the most common trauma found in the maxillofacial region. Thirty to forty percent of children incur at least one injury to their primary teeth and the incidence is not gender related.  The close proximity of the developing permanent tooth germ renders it vulnerable to trauma transmitted during an injury to deciduous teeth.  The type and severity of disturbance is dependent upon stage of tooth development, relationship of permanent tooth to the roots of primary tooth and direction and degree of force. ,
Dilaceration constitutes 3% of the total injuries to the developing tooth bud.  Dilaceration refers to an angulation or a sharp bend or curve in the root or crown of the formed tooth 
A 11-year-old girl reported to the Department of Pedodontics, The Oxford Dental College, Hospital and Research Center, Bangalore, with a chief complaint of an unerupted upper left front tooth. History revealed that the child had a history of trauma at the age of 2 years, following which she lost few of her upper front teeth. No dental treatment was taken for the same. Patient was asymptomatic and the only concern was regarding the unerupted permanent left upper front tooth. The age of eruption for the contralateral upper permanent central incisor was given as 8 years. Medical history was not contributory.
Intraoral examination revealed a bulge in the region of 21 and localized brownish discoloration of the incisal edge of 11 and 22 [Figure 1]. Intra-oral periapical [Figure 2] and occlusal radiographs of the maxillary anterior teeth showed a foreshortened crown in relation to 21 with two-third of root formation completed and with no bone covering the crown. A diagnosis of crown dilaceration was made on the basis of history and clinical finding.
After obtaining adequate anesthesia, the crown of 21 was surgically exposed [Figure 3]. The incisal half of the crown was observed to be palatally deviated (crown dilacerations). The exposed crown was kept under observation for any spontaneous eruption. However, no significant tooth movement was observed clinically and radiographically over a 3-month period. Orthodontic extrusion was then carried out using light continuous extrusive force [Figure 4], with weekly evaluation of the patient. The tooth was extruded in 3 months and adequate crown structure was available to gain access to the root canal [Figure 5]a and b. Thermal testing of the tooth gave no response. On extirpation, the pulp appeared to be necrotic. Apexification was carried out using Mineral Trioxide Aggregate MTA [Figure 6]. Root canal obturation was done after 24 h and glass ionomer cement was used to seal the access cavity [Figure 7]. Further restoration of the dilacerated crown was carried out using the technique described by Vitale et al.  The pulp chamber was prepared to receive a stump made with a suitable length of Glass Fiber Reinforced Composite Resin fibers (GFRCR). The length of this fiber stump was adjusted so as to have sufficient occlusal clearance. Following etching with orthophosphoric acid and application of Scotbond bonding agent (Scotbond 3M Dental products, St Paul, MN, USA), the prepared GFRCR fiber stump together with flowable composite was inserted into the pulp chamber and polymerized as a single unit [Figure 8]. An incremental core buildup of this stump was done with restorative composite resin. The morphology of the tooth was restored [Figure 9] and [Figure 10]. Composite veneering was done for 22 and 11.
Crown dilaceration usually involves the maxillary and mandibular incisors and is the result of avulsion or intrusion of their primary predecessors.  Generally, it is observed to occur between 1 and 3 years and rarely after 4 years. In the present case report, avulsion of 61 at the age of 2 years could have been the reason for crown dilaceration of 21. An indirect effect on the developing tooth buds of 11 and 22 could have resulted in a milder form of disturbance, i.e., the localized brown discoloration observed in these teeth.
Fifty percent of teeth with crown dilaceration become impacted.  Radiographically unerupted dilacerated teeth are seen as teeth foreshortened coronally. Clinically, the maxillary incisors show a lingual deviation while the mandibular incisors incline labially.  The dilacerated maxillary left central incisor reported here was also impacted. The preoperative radiograph showed foreshortening of the crown and on surgical exposure the incisal half showed a palatal deviation. These findings are in accordance with earlier reports of crown dilaceration. ,
The treatment options available are surgical exposure with or without orthodontic treatment, removal of dilacerated part of the crown, temporary crown until root formation, semi or permanent restoration and prosthetic or orthodontic space closure after extraction 
In the present case, the tooth failed to erupt after surgical exposure. A simple and effective method using orthodontic ligature wire was used to extrude the tooth. MTA was used as the apexification agent as a number of authors have reported clinical success using MTA for one visit apexification. , Apart from being a successful agent for single visit apexification procedures, MTA has demonstrated good sealability, biocompatibility and has been suggested of having some antimicrobial properties.  It was also very necessary to give the patient an esthetic, functional and durable restoration, until the time of restoration with a permanent crown. A previous study had used polyethylene fibers to create a central stump so as to increase the mechanical resistance of a composite restoration.  However, major drawback of these polyethylene fibers is their lower flexural strength and fracture resistance. They are also required to be prepared before placement.  Hence, we used GFRCR fibers, which have superior bond strength of 500 MPa and show an improved bonding with composite resin by interpenetration and polymer network formation.  Final restoration of the dilacerated tooth, together with composite veneering of the adjacent discolored teeth gave immense satisfaction to both child and parents. A 1-year follow-up presented with no signs and symptoms. The patient continues to be on periodic evaluation.
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