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Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 157-161

Multidisciplinary approach to the management of a subgingivally fractured anterior tooth using an aligner based esthetic orthodontic extrusion appliance – A case report

1 Department of Conservative Dentistry and Endodontics, KLE Society's Institute of Dental Sciences, Bengaluru, Karnataka, India
2 Department of Orthodontics and Dentofacial Orthopedics, KLE Society's Institute of Dental Sciences, Bengaluru, Karnataka, India

Date of Submission04-Jan-2019
Date of Decision01-Mar-2019
Date of Acceptance22-Mar-2019
Date of Web Publication23-Apr-2020

Correspondence Address:
Gayathri Parthiban
Rani Chennamma Ladies, Hostel, 20, Tumkur Road, 2nd Stage, Yeshwanthpur Suburb, Bengaluru - 560 022, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_3_19

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Restoration of a subgingivally fractured tooth, especially at anterior esthetic zones, is still a great challenge for restorative dentists. This case report describes the management of a subgingivally fractured central incisor of a healthy 27 year old male patient using a conservative approach while maintaining esthetics throughout the treatment with the help of a clear aligner. An interdisciplinary approach was followed that included nonsurgical endodontic therapy followed by orthodontic extrusion, crown lengthening, and post-endodontic restoration with a custom cast post and porcelain-fused-to-metal crown. The tooth was asymptomatic clinically and radiographically at 1-year follow-up. This method can be an innovative solution to patients who demand instant resolution to their esthetic issues. The present case also reports management of relapse of orthodontically extruded tooth.

Keywords: Esthetic, forced eruption, multidisciplinary communication, orthodontic extrusions

How to cite this article:
Parthiban G, Nagesh S, Karale R, Reddy S. Multidisciplinary approach to the management of a subgingivally fractured anterior tooth using an aligner based esthetic orthodontic extrusion appliance – A case report. Saudi Endod J 2020;10:157-61

How to cite this URL:
Parthiban G, Nagesh S, Karale R, Reddy S. Multidisciplinary approach to the management of a subgingivally fractured anterior tooth using an aligner based esthetic orthodontic extrusion appliance – A case report. Saudi Endod J [serial online] 2020 [cited 2022 Jan 25];10:157-61. Available from: https://www.saudiendodj.com/text.asp?2020/10/2/157/283139

  Introduction Top

Treatment of complicated crown-root fractures is a clinical challenge. With the recent trend shifting toward implants, conservative approaches to preserve the natural tooth are being overlooked.

In clinical situations where the biological width is not compromised, surgical crown lengthening alone would be sufficient to expose the subgingival margins. In situ ations where the fracture line extends subgingivally and an adequate crown ferrule is not achievable, root extrusion can be carried out orthodontically or surgically.

Heithersay, Ingber, and Simon described a method of orthodontically extruding teeth exhibiting transverse fractures in coronal one-third of the root.[1],[2],[3],[4] The objectives of forced eruption include preservation of biological width and exposure of sound tooth.[5] It allows the fracture line to be elevated above the epithelial attachment so that proper finish lines can be prepared.[6],[7] It keeps the bone ridge volume intact, which is useful if the patient opts for an implant in the future.[8] However, if there is any associated vertical root fracture or the presence of short roots, forced eruption should not be carried out, and other treatment options such as implants should be considered.[4] Another factor that affects treatment planning is the patient compliance, as orthodontic extrusion involves multiple visits. Surgical repositioning can be done in such situations, as a one-step procedure. However, it is invasive and requires postoperative splinting.[9] Hence, the final treatment plan should be comprehensive, taking into consideration all the above-mentioned factors. This case report outlines the multidisciplinary esthetic management of a complicated crown-root fracture N873.64 (Andreasen Modification of WHO Classification, 1981).[10]

  Case Report Top

A 27-year-old male patient reported to the hospital with a chief complaint of fractured maxillary right permanent central incisor (#11). Dental history revealed incomplete root canal treatment done 2.8 years back and the tooth was asymptomatic. The patient also gave a history of biting on hard food the previous day which led to the fracture of the same tooth. Gingival inflammation was present with respect to the tooth #11 with no mobility and no tenderness on percussion [Figure 1]a and b]. Medical history was noncontributory.
Figure 1: Clinical photographs showing the fractured central incisor (a) labial view. (b) Palatal view. (c) Diagnostic radiograph showing the fractured crown and the associated periradicular radiolucency

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Intraoral periapical radiographic investigation revealed a horizontal crown-root fracture with unfilled canal space and periapical pathology [Figure 1]c. Based on clinical and radiographic findings, the diagnosis was made as previously initiated root canal treatment of #11 with asymptomatic periapical periodontitis. Cone-beam computed tomography was not advised due to economic constraints. Treatment options such as orthodontic extrusion, immediate implant placement, fixed or removable prosthetics, and surgical repositioning were explained to the patient. After discussing in detail about the advantages and disadvantages of each procedure, the patient chose to retain the remaining tooth structure by forced orthodontic eruption. Written consent was obtained from the patient.

Phase I: Oral prophylaxis and nonsurgical endodontic treatment

After completing oral prophylaxis, the fractured fragment was temporarily reinforced with flowable composite resin to provide a seal during the root canal treatment. Conventional nonsurgical endodontic treatment was carried out. Access opening was done under rubber dam. Working length was determined with a radiograph and then confirmed with an electronic apex locator (Root ZX II, J. Morita Corp., Kyoto, Japan). Cleaning and shaping was down in a crown-down approach with ProTaper universal files (Dentsply Maillefer, Ballaigues, Switzerland) till F5 which has a diameter of 0.5 mm at D0 and 5% taper. Twenty milliliters of 5.25% NaOCl (Karnataka Fine Chem, Bangalore, India) was used for irrigation. Ca (OH)2(ApexCal, Ivoclar Vivadent, Liechtenstein) was placed as an intracanal medicament for a period of 2 weeks. The tooth was then obturated with corresponding gutta-percha cones with AH plus sealer (DeTrey Dentsply, Konstanz, Germany). A postoperative radiograph was obtained and was found to be satisfactory.

Impression of the upper arch was made, and a clear aligner was fabricated with 0.75-mm biostar sheet. The horizontally fractured crown fragment was removed under local anesthesia. Reattachment of the crown fragment was not considered as it was already discolored and fragile. After extracting the crown fragment, the fracture was found to be extending subgingivally in the palatal aspect.

Phase II: Clear aligner fabrication

Postspace was prepared till peeso reamer #3 [Figure 2]a. A J Hook was fabricated using a 0.8 mm stainless steel wire and cemented in the postspace using zinc phosphate cement (Harvard Cement; Harvard Dental GmbH, Berlin, Germany) [Figure 2]b and [Figure 2]c. The J Hook helped in delivering orthodontic force to the fractured segment. Since the patient was concerned about esthetics and did not agree for comprehensive orthodontic treatment, a passive clear aligner was fabricated before the removal of the fractured crown. The aligner was fabricated with the fractured segment as a template, and a temporary tooth was placed to provide adequate esthetics. The tooth segment was trimmed palatally to provide space for the J Hook and extrusive force application to the fractured segment [Figure 3]a and [Figure 3]b. Esthetic composite buttons were bonded to the adjacent tooth after etching with 37% phosphoric acid (Eazetch, Anabond Stedman, Chennai, India), and a universal bonding agent (Ortho Solo, Ormco, California, USA) was applied. Elastomeric separators were used as a template, and bondable buttons were fabricated using flowable composite (Enlight, Ormco, California, USA) and cured with LED curing light (Ivoclar Bluephase G2, Liechtenstein) with an intensity of 1200 mW/cm2 for 10 s. From the buttons, an elastomeric chain was placed to the J Hook to deliver 40 g extrusive force [Figure 3]c, which was measured using a Dontrix Gauge (D Tech Dental Technologies, Pune, India). In addition, two teeth on either side were bonded with a 0.016” A.J. Wilcock wire to reinforce anchorage and also to counteract the reactive intrusive force on the adjacent teeth. The J Hook and the elastic chain were concealed beneath the aligner [Figure 3]d.
Figure 2: (a) Radiograph showing the prepared postspace. (b) Radiograph showing the fit of J Hook in the postspace. (c) Clinical view of the J Hook luted with zinc phosphate cement

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Figure 3: The passive aligner with artificial tooth (a) labial view. (b) Occlusal view. (c) Esthetic buttons bonded to adjacent teeth and elastic chain placed to the J Hook. (d) Passive clear aligner in place

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The force module was changed every 3 weeks. After 3 months, 3-mm extrusion was observed [Figure 4]a and b]. Expecting some amount of relapse, 4 weeks of stabilization period was given before a permanent crown was made.
Figure 4: Radiograph showing tooth #21 (a) before and (b) after extrusion and final restoration. Notice the amount of the distance of the extrusion. (c) Mild relapse of 0.5 mm intrusion noticed at the end of 1 month. (d) Fixed lingual bonded retainer in place. Follow-up at 1 year. (e) Clinical view and (f) radiographic view showing resolution of periapical lesion

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Phase III: Crown lengthening

Electrosurgery (Bonart ART-E1, Remedy Deals, Delhi, India) was performed under local anesthesia on the palatal aspect to reestablish the gingival margin and convert the subgingival fracture site to a supragingival one. Gingivectomy was carried out to remove 1 mm of gingival tissue. There was no need for any resective procedure involving the bone. Soft-tissue healing was found to be satisfactory after a month.

Phase IV: Postendodontic restoration

Postendodontic restoration was done with cast post and a metal-ceramic crown. It was fabricated using Ni-Cr alloy (Ni: 65.2%, Cr: 22.5%, Mo: 9.5%) (Bego, Bremen, Germany) and porcelain (Vita, Bad Sackingen, Germany). The final crown was cemented over the prepared tooth using Type I luting glass ionomer cement (GC Corporation, Tokyo, Japan), and occlusion was checked to eliminate any premature contact. At a follow-up examination at 1, 3, 6, 8, and 12 months, the patient was asymptomatic, and his periodontal health was found to be satisfactory. However, a 0.5 mm of relapse was observed after 1 month of final restoration [Figure 4]c. The patient was given a fixed lingual bonded retainer, and esthetic recontouring of the adjacent central incisor was done to mask the mild discrepancy [Figure 4]d. The tooth was asymptomatic clinically and radiographically at 1-year follow-up [Figure 4]e and [Figure 4]f.

  Discussion Top

The treatment strategy for a crown-root fracture is complex, and esthetics is an important requirement. Considering long-term prognosis, extraction and placement of an implant would be an ideal treatment option. However, the patient wanted a noninvasive and a cost-effective treatment. Hence, orthodontic extrusion was considered.

Orthodontic extrusion is a conservative procedure that allows retention of a tooth without loss of bone or periodontal support.[11] It has been demonstrated in experimental and clinical studies that levels of gingival attachment and bone will follow the extrusive movement for single tooth. Proffit recommends an ideal force level of 35–60 g for orthodontic extrusion. Force application in this ranges provides a physiological bone response.[12] A light force of 40 g was used in this case to achieve extrusion of the fractured segment and good alveolar bone response.

Various methods have been described in the literature regarding the method of application of orthodontic extrusion force. A simplistic method of orthodontic extrusion was described by Patil et al. using a wire with vertical bends that were bonded to the adjacent teeth. Orthodontic force was given from the attachments on the fractured teeth to the vertical bends using elastomeric chains.[6] Another method was described by Fidel et al. which involved bonding brackets from canine to canine in the upper arch and delivering low-intensity orthodontic forces through archwires.[13] Alotaibi described a method in which a temporary acrylic crown was used in conjunction with orthodontic brackets for extrusion.[14] However, in all these techniques, the extrusion appliance would be visible externally during the course of treatment. In the present case, the patient did not agree for the placement of any noticeable orthodontic attachments. Hence, an innovative method to conceal the extrusion apparatus with an aligner and pontic was designed.

Murali et al. suggested a lingual technique using STB brackets.[15] Even though the lingual appliance is more esthetic, alignment of the rest of the teeth is necessary, and hence, this approach was not preferred.

The patient demanded an esthetic appearance throughout the treatment. That was the reason to resort to the use of an aligner to maintain the esthetics. The use of J Hook for extrusion delivered the force along the long axis of the tooth. This was to prevent other unwanted tooth movement that occurs when the point of force application is from an attachment on the tooth. Although reattachment of the fractured tooth fragment has been carried out in literature as a viable technique to restore function and esthetics,[16] it could not be carried out in the present case considering the discolored nature and fragility of the fractured fragment.

Postorthodontic extrusion, 3–6 weeks of stabilization period, is recommended to allow reorganization of the periodontal ligament.[12] Longer stabilization periods can help in reduction of relapse tendencies. In general, a temporary crown may be advised for 2 months before fabrication of the permanent crown to ensure stability. In some cases, a bonded retainer or supracrestal fibrotomy can be done to prevent relapse. The present case showed 1 mm of relapse in spite of providing a stabilization period of 4 weeks. Bonded retainer was given to prevent further relapse and was monitored at regular intervals. The tooth was stable at 1-year follow-up.

Surgical repositioning of the fractured segment is another alternative to orthodontic extrusion. It is faster, and about 4.5 mm of extrusion can be achieved. However, the most important disadvantage of this procedure is the loss of alveolar bone support following the surgery. Hence, this procedure might not give a favorable outcome if the patient wants to opt for an implant at a later stage. Furthermore, care should be taken to maintain the integrity of the periodontal ligament and cementoblasts. Gradually, repositioning should be done toward the occlusal plane, and splinting should be carried out. Thus, it is considered more complicated and time-consuming.[9]

In the present case, considering the preoperative status of the tooth, extraction followed by single tooth immediate implant placement would be a more predictable treatment option. However, many factors such as invasiveness and patient's affordability were taken into consideration. Furthermore, studies have shown that achieving esthetics and gingival architecture is very tedious with implants, especially in patients with a high smile line, greater distances between interproximal contact point and alveolar bone, or a thin, scalloped periodontal biotype. Another possible limitation is the supraeruption of natural teeth, which could occur even in adult patients with completed craniofacial growth. This might lead to unesthetic horizontal steps at the incisor line and the gingival margins between implant and tooth.[17]

A systematic review by Tomasi et al. suggests that the loss rate of implants is higher than that of natural teeth in clinically well-maintained patients. Therefore, minimally invasive treatment options should be considered before opting for implants.[18] Another review by Al Shareef and Saad states that the long-term prognosis of an endodontically treated tooth and single tooth implants do not differ significantly. Hence, all efforts should be made to preserve the natural tooth. Endodontic treatment followed by postendodontic restoration will be an economic and practical way to maintain function and esthetics.[19]

Several cases have been reported in the literature that proves orthodontic extrusion to be predictable and stable.[5],[7],[20],[21] A comparative study by Carvalho et al. concluded that the long-term outcome and stability of gingival margin and bone tissue is better when orthodontic extrusion is combined with fibrotomy.[22] However, in the present case, since the patient did not agree for an invasive procedure like fibrotomy, lingual bonded retainer was given for long-term stability.

Thus, the present case report reinforces on the time-tested treatment option of orthodontic extrusion of a subgingivally fractured tooth with a novel approach to maintain esthetics throughout the procedure in a cost-effective way.

  Conclusion Top

Immediate esthetic resolution using a passive clear aligner is an immediate and less expensive method, which offers satisfactory esthetic and functional rehabilitation of the fractured tooth.

Extrusion of the tooth with optimal orthodontic forces can give good physiological tooth and bone response. Hence, these minimally invasive approaches should be thought of before resorting to implants.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Heithersay GS, Moule AJ. Anterior subgingival fractures: A review of treatment alternatives. Aust Dent J 1982;27:368-76.  Back to cited text no. 1
Ingber JS. Forced eruption: Alteration of soft tissue cosmetic deformities. Int J Periodontics Restorative Dent 1989;9:416-25.  Back to cited text no. 2
Simon JH, Kelly WH, Gordon DG, Ericksen GW. Extrusion of endodontically treated teeth. J Am Dent Assoc 1978;97:17-23.  Back to cited text no. 3
Bach N, Baylard JF, Voyer R. Orthodontic extrusion: Periodontal considerations and applications. J Can Dent Assoc 2004;70:775-80.  Back to cited text no. 4
Kondapuram Seshu MR, Gash CL. Multidisciplinary management of a fractured premolar: A case report with followup. Case Rep Dent 2012;2012:192912.  Back to cited text no. 5
Patil SS, Panicker AS, Hindlekar A, Srinidhi SR, Dhumal A, Vhora K. Forced orthodontic extrusion for anterior traumatized teeth by a simplistic approach. J Dent Allied Sci 2014;3:111-3.  Back to cited text no. 6
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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