Multidisciplinary Approach To The Management of A Subgingivally Fractured Tooth

Multidisciplinary approach to the management of
a subgingivally fractured anterior tooth using an

aligner based esthetic orthodontic extrusion
appliance – A case report
Saudi endodontic journal Sept 2020
Dr. Najla T.P

INTRODUCTION
• Treatment of complicated crown‑root fractures is a clinical challenge.
• With the trend shifting toward implants, conservative approaches to preserve the natural
tooth are being overlooked.
• If the fracture line extends subgingivally and adequate crown ferrule is not achievable,
root extrusion can be carried out orthodontically .
• The objectives of orthodontic extrusion include preservation of biological width and

exposure of sound tooth. It allows fracture line to be elevated above the epithelial
attachment so that proper finish lines can be prepared.
• But , if there is any associated vertical root fracture or the presence of short roots,
orthodontic extrusion should not be carried out.
• This case report outlines the multidisciplinary esthetic management of a complicated

crown‑root fracture .
CASE REPORT
• 27‑year‑old male patient reported with 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 gave a history of biting on hard food 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.
• Medical history was non contributory.

• Intraoral periapical radiograph revealed horizontal crown‑root fracture
with unfilled canal space and periapical pathology .
• Based on clinical and radiographic findings, the diagnosis was made as

previously initiated root canal treatment of #11 with asymptomatic
periapical periodontitis.
• Treatment options such as orthodontic extrusion, implant placement,
fixed or removable prosthetics, and surgical repositioning were
explained to the patient.
• The patient chose to retain the remaining tooth structure by forced

orthodontic extrusion.
• 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 and working length determined.
• BMP was performed , 20 ml of 5.25% NaOCl was used for irrigation.

• Ca (OH)2 was placed as an intracanal medicament for a period of 2
weeks.
• The tooth was then obturated with gutta‑percha cones with AH plus
sealer .
• 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 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 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 removing the crown fragment, the fracture was found to be extending
subgingivally in the palatal aspect.
Phase II: Orthodontic Extrusion and Clear aligner placement
• Post space was prepared till peeso reamer #3 .
• J Hook was fabricated using a 0.8 mm stainless steel wire and cemented in
the post space using zinc phosphate cement .
• The J Hook helped in delivering orthodontic force to the fractured segment.
• Esthetic composite buttons were fabricated using flowable composite ,
cured and bonded to the adjacent tooth after etching with 37%
phosphoric acid and applying universal bonding agent .
• From the buttons, an elastomeric chain was placed to the J Hook to

deliver 40 g extrusive force.
• 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 clear aligner was then placed on the teeth.
• The J Hook and the elastic chain were concealed beneath the aligner .
• The force module was changed every 3 weeks.
• After 3 months, 3‑mm extrusion was observed .
• Expecting relapse, 4 weeks of stabilization period was given before a

permanent crown was made.
Phase III: Crown lengthening
• Electrosurgery was performed to remove 1 mm of gingival tissue on the
palatal aspect to reestablish the gingival margin and convert the
subgingival fracture site to a supragingival one.
• 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.
• 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
• The patient was given a fixed lingual bonded

retainer, and esthetic recontouring of the
adjacent central incisor was done to mask the
mild discrepancy .
• The tooth was asymptomatic clinically and

radiographically at 1‑year follow‑up .
DISCUSSION
• The treatment strategy for a crown‑root fracture is complex, and
esthetics is an important requirement.
• Since the patient wanted a noninvasive and a cost‑effective treatment ,

orthodontic extrusion was considered.
• Orthodontic extrusion is a conservative procedure that allows retention

of a tooth without loss of bone or periodontal support.
• 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.
• A light force of 40 g was used in this case to achieve extrusion of the

fractured segment and good alveolar bone response.
• The patient demanded an esthetic appearance throughout the treatment.
• That was the reason to resort to the use of a clear aligner to maintain the
esthetics.
• The use of J Hook for extrusion delivered the force along the long axis
of the tooth which prevented other unwanted tooth movement.
• Post orthodontic extrusion, 3–6 weeks of stabilization period, is
recommended to allow reorganization of the periodontal ligament.
• In general, a temporary crown may be advised for 2 months before

fabrication of the permanent crown to ensure stability.
• The present case showed 0.5 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

• Several cases have been reported in the literature that proves orthodontic
extrusion to be predictable and stable.
• 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.
• 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 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
• 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 other treatment options.
REFERENCES
• 1. Heithersay GS, Moule AJ. Anterior subgingival fractures: A review of treatment alternatives. Aust
Dent J 1982;27:368‑76.
• 2. Ingber JS. Forced eruption: Alteration of soft tissue cosmetic deformities. Int J Periodontics
Restorative Dent 1989;9:416‑25.
• 3. Simon JH, Kelly WH, Gordon DG, Ericksen GW. Extrusion of endodontically treated teeth. J Am
Dent Assoc 1978;97:17‑23.
• 4. Bach N, Baylard JF, Voyer R. Orthodontic extr usion: Periodontal considerations and applications. J
Can Dent Assoc 2004;70:775‑80.
• 5. Kondapuram Seshu MR, Gash CL. Multidisciplinary management of a fractured premolar: A case
report with followup. Case Rep Dent 2012;2012:192912.
• 6. 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.
• 7. Mittal R, Gupta S, Singla A, Gupta A. Managing sub ‑gingival fracture by multi ‑disciplinary approach:
Endodontics‑forced orthodontic extrusion and prosthetic rehabilitation. Saudi Endod J 2013;3:82 ‑6.
• 8. Devanna R, Hegde V, Kavitha V. Management of subgingivally fractured teeth: A multidisciplinary
approach. J Interdiscip Dent 2011;1:49‑54
• 9. Calişkan MK, Türkün M, Gomel M. Surgical extrusion of crown‑root ‑fractured
teeth: A clinical review. Int Endod J 1999;32:146‑51.
• 10. 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. JIndian Soc Pedod Prev Dent 2006;24:197‑200.
• 11. Bajaj P, Chordiya R, Rudagi K, Patil N. Multidisciplinary approach to the
management of complicated crown‑root fracture: A case report. J Int Oral Health
2015;7:88‑91.
• 12. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 6th ed. St
Louis, Missouri: Mosby; 2013.
• 13. Fidel SR, Fidel‑Junior RA, Sassone LM, Murad CF, Fidel RA. Clinical
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• 14. Alotaibi BB. Multidisciplinary approach to the treatment of a complicated
crown‑root fracture. Saudi Endod J 2019;9:56‑60.
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– An invisible approach. Indian J Multidiscip Dent 2011;1:96‑99
• NEXT PRESENTATION ON :
Adaptable fibre glass post after 3 D guided endodontic
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Multidisciplinary approach to the management of

a subgingivally fractured anterior tooth using an

Dr. Najla T.P

• The objectives of orthodontic extrusion include preservation of biological width and

• This case report outlines the multidisciplinary esthetic management of a complicated

• Dental history revealed incomplete root canal treatment

• The patient gave a history of biting on hard food which led

• Gingival inflammation was present with respect to the tooth

• Medical history was non contributory.

• Based on clinical and radiographic findings, the diagnosis was made as

• The patient chose to retain the remaining tooth structure by forced

• Written consent was obtained from the patient.

• After completing oral prophylaxis, the fractured fragment was

• Conventional nonsurgical endodontic treatment was carried out.

• Access opening was done and working length determined.

• BMP was performed , 20 ml of 5.25% NaOCl was used for irrigation.

• A postoperative radiograph was obtained and was found to be

• From the buttons, an elastomeric chain was placed to the J Hook to

• The force module was changed every 3 weeks.

• After 3 months, 3‑mm extrusion was observed .

• Expecting relapse, 4 weeks of stabilization period was given before a

• Soft‑tissue healing was found to be satisfactory after a month.

• Postendodontic restoration was done with cast post and a metal‑ceramic

• At a follow‑up examination at 1, 3, 6, 8, and 12 months, the patient was

• The patient was given a fixed lingual bonded

• The tooth was asymptomatic clinically and

• Since the patient wanted a noninvasive and a cost‑effective treatment ,

• Orthodontic extrusion is a conservative procedure that allows retention

• It has been demonstrated in experimental and clinical studies that levels

• A light force of 40 g was used in this case to achieve extrusion of the

• The patient demanded an esthetic appearance throughout the treatment.

• In general, a temporary crown may be advised for 2 months before

• The present case showed 0.5 mm of relapse in spite of providing a

• The tooth was stable at 1‑year follow‑up

• A comparative study by Carvalho et al. concluded that the long‑term

• Thus, the present case report reinforces on the treatment option of

• Immediate esthetic resolution using a passive clear aligner is an

• Hence, these minimally invasive approaches should be thought of

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