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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 5  |  Page : 678-680
Orthodontic extrusion of subgingivally fractured tooth using a removable appliance: An alternative treatment to reestablish biological width


1 Department of Pedodontics and Preventive Dentistry, Surendra Dental College and Hospital, Sriganganagar, Rajasthan, India
2 Department of Orthodontics, Institute of Dental Sciences, Sehora Jammu, India

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Date of Submission26-May-2014
Date of Decision18-Jun-2014
Date of Acceptance25-Aug-2014
Date of Web Publication16-Dec-2014
 

   Abstract 

Restoration of a traumatically injured tooth presents a clinical challenge for a predictable aesthetic outcome. This case report describes a multidisciplinary approach of a subgingivally fractured permanent maxillary central incisor. A removable orthodontic appliance was used for orthodontic extrusion of root, and surgical gingival recontouring was done with electrocautery to reestablish the biological width. Form and function were restored establishing biological width and esthetics was repaired with porcelain fused to metal crown.

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

How to cite this article:
Verma KG, Juneja S, Kumar S, Goyal T. Orthodontic extrusion of subgingivally fractured tooth using a removable appliance: An alternative treatment to reestablish biological width. Indian J Dent Res 2014;25:678-80

How to cite this URL:
Verma KG, Juneja S, Kumar S, Goyal T. Orthodontic extrusion of subgingivally fractured tooth using a removable appliance: An alternative treatment to reestablish biological width. Indian J Dent Res [serial online] 2014 [cited 2019 Jul 16];25:678-80. Available from: http://www.ijdr.in/text.asp?2014/25/5/678/147128
Traumatic injuries to teeth and their supporting tissues usually occur in young people aged 6-13 years, with damage varying from enamel fracture to avulsion, with or without pulpal involvement or bone fracture. [1] A crown-root fracture comprises 5% of all traumatic injuries, resulting from horizontal impact and involving enamel, dentin, and cementum. [2] Maxillary anterior teeth are most often affected, and 80% of them are maxillary central incisors. [1] Indication of treatment depends on the level of fracture line and the amount of remaining tooth structure. The subgingivally fractured teeth present a complex treatment strategy due to difficulties preserving the gingival biologic width. They are difficult to restore and hence often extracted. The form and function of the tooth are restored through a comprehensive and multidisciplinary treatment plan. Several methods [3],[4],[5] have been described for root fracture treatment; (1) crown lengthening procedures using periodontal surgery (2) orthodontic extrusion or forced eruption. Extrusion closely resembles natural tooth eruption maintaining a crown-root ratio of approximately 1:1. A force of 0.2-0.3 N is required for extrusion of single-rooted tooth with 2-4 mm movement for central incisor and 4-6 mm for lateral incisor. [6] Biologic width realignment is required to obtain proper gingival and crestal bone contour. The 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 case report presents a multidisciplinary management of a subgingivally fractured tooth using orthodontic extrusion with removable appliance, re-establishing biological width by periodontal surgery and final restoration using porcelain fused to metal crown.


   Case report Top


A 14-year-old male patient reported to the department of pediatric and preventive dentistry with the chief complaint of fractured maxillary right permanent central incisor. Past dental history revealed that the tooth was the root canal treated 2.8 years back and was asymptomatic. A day before, patient met with trauma that caused uncomplicated subgingival fracture of the same tooth at cervical third of the root [Figure 1]a. Gingival inflammation was reported with respect to a fractured tooth that is, 11, with no mobility and tenderness on percussion. Past medical history was reviewed, and there was no remarkable report. Clinical and radiographic maxillofacial examination revealed that there was no fracture of the maxilla, mandible, or other facial bones. Intraoral periapical radiographic investigation revealed a horizontal crown-root fracture with intact obturated root canal and no periapical pathology [Figure 1]b. On the basis of clinical and radiographic findings, a definite treatment plan was made and explained to patient's guardians. Post space was prepared, and a prefabricated gold post was cemented in the canal using glass ionomer cement Type I luting cement [Figure 1]c and d. Orthodontic extrusion of the fractured permanent maxillary central incisor was required to move the palatal fracture line approximately 3 mm above the alveolar crest in order to regain the lost biologic width. Orthodontic traction was applied using a removable maxillary appliance with V-shaped bend with respect to area of maxillary right central incisor [Figure 2]a. V-shaped bend was placed approximately 5-6 mm below the alveolar crest level of tooth. Extrusive force was applied using ligature wire tied with post and V-bend. Ligature wire was changed every week to assure continuous traction force and regular oral hygiene maintenance below the maxillary appliance. An extrusion of 3 mm was obtained in 2 months, which was appreciated clinically and radiographically [Figure 2]b-d. The circumferential supra-crestal fibrotomy was performed using electrocautery to prevent relapse [Figure 3]a and b. Core build-up was done, and tooth was restored with porcelain fused to metal crown [Figure 3]c and d. The written informed consent form was signed by his parents for treatment and further publication of the case.
Figure 1: (a) Intraoral picture depicting uncomplicated subgingival fracture of the maxillary right permanent central incisor; (b) intraoral periapical (IOPA) revealing a horizontal crown-root fracture; (c) prefabricated gold post cemented in the canal; (d) IOPA revealing cemented gold post

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Figure 2: (a) Orthodontic traction with removable maxillary appliance with V-shaped bend; (b) labial view of extruded tooth; (c) palatal view of extruded tooth; (d) intraoral periapical showing 3 mm of a significant extrusion

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Figure 3: (a) Supra-crestal fibrotomy performed using electrocautery; (b) labial view of the tooth after gingival recontouring; (c) core build-up with crown cutting; (d) porcelain fused to metal crown wrt 11

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   Discussion Top


The location of fracture line affects the treatment options, clinical outcomes, and prognosis of teeth. Those fractured in the subgingival area have been found to be the bleakest because of the loss of the coronal fragment stability and pulpal vitality. [8] Root canal therapy is advised for those teeth in which pulp neurovascular supply is disrupted, to avoid pulp necrosis that can lead to external inflammatory root resorption.

The 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] There are various treatment options of tooth fracture involving the biologic width: Root extrusion technique, crown lengthening procedures and combination of both. [4] Considering the maintenance of form and function of the tooth, the orthodontic treatment was planned followed by gingival contouring with reestablishment of biological width. Prefabricated threaded gold post was cemented into the root canal with self-curing luting cement, as it provides the best seal despite their technique sensitivity.

The extrusive force was applied using a removable appliance with a V-shaped bend. This technique shows the advantage over the traditional methods being simple method of orthodontic extrusion, low-cost factor, and prevention of relapse.

To prevent relapse, after supra-crestal fibrotomy, prolonged retention is required for approximately 2 months. Heda et al., [9] in his case report suggested performing fibrotomy just after the orthodontic movement is finished, even twice after 4 weeks interval. Heithersay reported that in some cases, in order to avoid relapse, the over-extrusion of the tooth may be necessary. [10] This treatment is preferred over crown lengthening which removes alveolar bone and may become the reason for pocket formation.

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


   Conclusion Top


Pediatric patients are more often prone to traumatic injuries to maxillary anterior teeth that require a multidisciplinary approach. It is the duty of the pedodontist to achieve an adequate coronal seal during these lengthy procedures and restoring periodontal health, esthetics, and patient confidence.

 
   References Top

1.
Zerman N, Cavalleri G. Traumatic injuries to permanent incisors. Endod Dent Traumatol 1993;9:61-4.  Back to cited text no. 1
    
2.
Ulusoy AT, Tunc ES, Cil F, Isci D, Lutfioglu M. Multidisciplinary treatment of a subgingivally fractured tooth with indirect composite restoration: A case report. J Dent Child (Chic) 2012;79:79-83.  Back to cited text no. 2
    
3.
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. 3
    
4.
Johnson RH. Lengthening clinical crowns. J Am Dent Assoc 1990;121:473-6.  Back to cited text no. 4
    
5.
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. 5
    
6.
Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4 th ed. Oxford: Blackwell; 2007. p. 325-8.  Back to cited text no. 6
    
7.
Potashnick SR, Rosenberg ES. Forced eruption: Principles in periodontics and restorative dentistry. J Prosthet Dent 1982;48:141-8.  Back to cited text no. 7
    
8.
Welbury R, Kinirons MJ, Day P, Humphreys K, Gregg TA. Outcomes for root-fractured permanent incisors: A retrospective study. Pediatr Dent 2002;24:98-102.  Back to cited text no. 8
    
9.
Heda CB, Heda AA, Kulkarni SS. 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.  Back to cited text no. 9
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10.
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. 10
    

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Correspondence Address:
Kanika Gupta Verma
Department of Pedodontics and Preventive Dentistry, Surendra Dental College and Hospital, Sriganganagar, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.147128

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