Clinical management of a complicated crown-root fracture of maxillary central incisor in a 12-year-old patient

Abstract

Traumatic injuries to permanent maxillary anterior teeth are seen commonly in children. Esthetic and functional rehabilitation of these teeth is important. A 12-year-old male patient reported to the Department of Paedodontics and Preventive Dentistry with fracture of the permanent maxillary right central incisor. Clinical and radiographic examinations revealed the presence of a complicated crown-root fracture. This case report describes the management of complicated crown-root fracture by endodontic therapy, orthodontic extrusion, fiber post placement, core build-up with composite, and esthetic restoration using polycarbonate crown.

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© 2018 International Journal of Pedodontic Rehabilitation | Published by Wolters Kluwer - Medknow
76
Case Report
IntroductIon
Traumatic injuries to teeth and their supporting tissues usually
occur in children and damage may vary from enamel fracture
to avulsion, with or without pulpal involvement or alveolar
bone fracture. A crown-root fracture is a type of dental trauma,
usually resulting from horizontal impact, which involves
enamel, dentin, and cementum, occurs below the gingival
margin,andmaybeclassiedascomplicatedoruncomplicated,
depending on the presence or absence of pulp involvement.[1,2]
Crown-root fractures of permanent anterior teeth in young
patients lead to functional and esthetic problems.[3,4] The most
commonly affected tooth is the maxillary central incisor (58.3%).
Crown-root fractures in maxillary arch are seen commonly
between 11- and 18-year-old adolescents and frequently present
treatment problems due to the complex nature of the injury.[5-7]
This case report describes the management of complicated
crown-root fracture by endodontic treatment, orthodontic root
extrusion, and esthetic restoration using polycarbonate crown
in a 12-year-old male patient.
case report
A 12-year-old boy reported to the Department of Paedodontics
and Preventive Dentistry, Terna Dental College with the chief
complaint of broken upper front tooth. The patient had a
history of trauma to the anterior teeth 5 days ago due to fall
whileplaying.Themedicalhistorywasnotsignicantand
thendingsoftheextraoralexaminationwereunremarkable.
Intraoral examination revealed a complicated crown-root
fracture in the maxillary right central incisor with a mobile
tooth fragment that extended subgingivally in the palatal
region [Figure 1]. Radiographic examination using intraoral
periapicalradiographconrmedthendingsoftheclinical
examination; the fracture line on the palatal side could be
traced 2 mm below the alveolar crest. Closed apex was
present with maxillary right central incisor. The periodontal
space around the tooth appeared to be normal, and there were
nopathologicndingsinadjacentteeth[Figure 2].
Onthebasisofclinicalandradiographicndings,adiagnosis
of complicated crown-root oblique fracture, Andreasen’s
classication502.54wasmade.
Clinical Management of a Complicated Crown‑Root Fracture of
Maxillary Central Incisor in a 12‑Year‑Old Patient
Ashveeta J. Shetty, Farhin Katge1, Manohar Poojari1, Chirag Punamiya2
Department of Pedodontics and Preventive Dentistry, School of Dentistry, DY Patil University, Navi Mumbai, 1Department of Paedodontics and Preventive Dentistry,
Terna Dental College, 2Dr. Chirag’s Dental Care Centre, Mumbai, Maharashtra, India
Address for correspondence: Dr. Ashveeta J. Shetty,
Department of Pedodontics and Preventive Dentistry, School of Dentistry,
DY Patil University, Sector 7, Highway Road, DY Patil Vidyanagar, Nerul,
Mumbai, Maharashtra ‑ 400 706, India.
E‑mail: ashveeta@gmail.com
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DOI:
10.4103/ijpr.ijpr_8_18
How to cite this article:ShettyAJ,KatgeF,PoojariM,PunamiyaC.Clinical
management of a complicated crown-root fracture of maxillary central incisor
in a 12-year-old patient. Int J Pedod Rehabil 2018;3:76-9.
Traumatic injuries to permanent maxillary anterior teeth are seen commonly in children. Esthetic and functional rehabilitation of these teeth
is important. A 12-year-old male patient reported to the Department of Paedodontics and Preventive Dentistry with fracture of the permanent
maxillary right central incisor. Clinical and radiographic examinations revealed the presence of a complicated crown-root fracture. This case
reportdescribesthemanagementofcomplicatedcrown‑rootfracturebyendodontictherapy,orthodonticextrusion,berpostplacement,core
build-up with composite, and esthetic restoration using polycarbonate crown.
Keywords:Crown‑rootfracture,glassberpost,orthodonticextrusion,polycarbonatecrown,trauma
Abstract
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Shetty, et al.: Clinical management of a complicated crown‑root fracture
International Journal of Pedodontic Rehabilitation ¦ Volume 3 ¦ Issue 2 ¦ July-December 2018 77
Adenitive treatment plan was made as follows: removal
of fractured fragment under local anesthesia followed
by endodontic therapy of residual tooth. Following this,
orthodontic extrusion to move the fracture line 3 mm above
the alveolar crest was planned to regain the lost biologic width.
The treatment option was explained to the parents and consent
was obtained for the treatment.
Anesthesiawas established bylocalinltration of lidocaine
with 1:80,000 adrenaline. After removal of the loose fragment,
the tooth margin was clinically visible on the labial side but
not on the palatal side. Probing with a periodontal probe
revealed that the tooth margin on the palatal side was located
subgingivally and below the alveolar crest level.
Root canal treatment was initiated. After preparing an endodontic
access cavity, the root canal working length was determined to
be 20 mm with a periapical radiograph. The canal was prepared
using ProTaper® rotary instruments (Dentsply-Maillefer,
Switzerland) till F2.After the canal preparation, F2 size
gutta-percha cone was lightly coated with an epoxy resin-based
sealer (AH Plus Jet, DentsplyDeTrey, Konstanz, Germany) and
the root canal treatment was completed [Figure 3].
Post space was prepared with the help of Peeso reamer size
3 (Mani, INC, Japan) [Figure 3]. A “J” shaped post hook was
prepared using 19-gauge stainless steel wire and cemented with
glass ionomer cement. Brackets were placed on maxillary right
lateral incisor and left central incisor. Extrusion was activated by
elastic which was attached to the brackets and “J” hook. Within
a span of 2 weeks, 1 mm extrusion was observed [Figure 4].
However, 1 mm mesial tipping of maxillary right lateral incisor
was also observed. Hence, brackets were also placed on both
right maxillary premolars, and E chain was placed to reposition
the right lateral incisor [Figure 5]. Within 4 weeks, the desirable
3 mm extrusion was observed along with repositioning of
the right lateral incisor. The brackets and J hook were then
debonded [Figure 5].
Glass ber post (Reforpost,Angelus® Ind. e Com Ltda.
Londrina, PR, Brazil) was placed into the root canal
for supporting the coronal fragment. Size 2 glass fiber
post (Reforpost, Angelus® Ind. e Com Ltda. Londrina, PR,
Brazil) with a 1.4 mm diameter was placed at the length of 12 mm
and was luted. After cutting the excessive post, core buildup
was done using composite resin (SDI, Australia) [Figure 6].
Tooth preparation was done to receive polycarbonate crown.
Followingtoothpreparationandnecessaryadjustmentsinthe
crown, the polycarbonate crown was cemented using luting
glass ionomer cement and postoperative radiograph was
taken(Fuji1,GCEurope)[Figure 7].
dIscussIon
Forcasesofcomplicatedcrown‑rootfractures,thereareseveral
proposedtreatmentoptionsincludingamucogingivalap,an
osteotomy/osteoplasty, and orthodontic or surgical extrusion
followed by the reattachment of the original fragment. Another
option includes the restoration of the tooth crown with a
restorative material or prosthetic rehabilitation of the tooth
depending on the location of the fracture line.[8-10] Extraction
is also an option followed by tooth replacement.
Orthodontic extrusion of a fractured tooth maintains the
periodontal tissues at the same level and restores physiological
Figure 2: Preoperative intraoral periapical radiograph showing radiolucent
line seen below cementoenamel junction.
Figure 1: Preoperative intraoral photograph showing complicated crown‑
root fracture with right maxillary central incisor.
Figure 3: Root canal treatment with 11 done with rotary ProTaper files
followed by postspace preparation.
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Shetty, et al.: Clinical management of a complicated crown‑root fracture
International Journal of Pedodontic Rehabilitation ¦ Volume 3 ¦ Issue 2 ¦ July-December 2018
78
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.[11] The forced
eruption should be maximum 5 mm according to Ingle and
was limited to 3 mm in the present case.[12] Orthodontic
extrusion leads to supragingival positioning of the fracture
line.
To reinforce the cervical portion of the tooth to receive a
coronal restoration, it is recommended to use an intracanal
post. The post also minimizes the stresses.[13] It has
been suggested that the use of a long, thin ber post is
effective for reducing the tensile stress that can lead to
tooth root fractures of the anterior teeth with endodontic
treatments.[14] In the present case, the fracture line was
extending subgingivally, and the tooth required root canal
treatment. Hence, it was decided to gain intraradicular
retentionusingberposts.
At 6-month follow-up, patient was asymptomatic. Clinical
evaluation revealed 0.5 mm apical migration of gingival margin
and incisal edge of 11. However, there was no tooth mobility
or periodontal pocket formation. Radiographic evaluation at
6 months revealed no abnormality [Figure 8].
Long-term follow-up of the present case is needed to
ascertain the long-term clinical success based on clinical and
radiographic examinations.
conclusIon
Crown-root fractures localized in the anterior region need
to be evaluated from several perspectives including tooth
vitality, tissues involved, fracture location, and the quantity
of remaining tooth structure. In the present case, a tooth
with complicated crown-root fracture was successfully
managedbyendodontictherapy,orthodonticextrusion,ber
post placement, core build-up with composite, and esthetic
restoration using polycarbonate crown. Long-term follow-up is
required to evaluate the long-term clinical success of the case.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the legal guardian has
given his consent for images and other clinical information
to be reported in the journal. The guardian understands that
names and initials will not be published and due efforts will
be made to conceal patient identity, but anonymity cannot
be guaranteed.
Figure 4: Intracanal J hook placement and brackets placement.
Figure 6: Core buildup and tooth preparation.
Figure 5: Distalization of right lateral incisor.
Figure 7: Postoperative photograph and radiograph following cementation
of polycarbonate crown.
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Shetty, et al.: Clinical management of a complicated crown‑root fracture
International Journal of Pedodontic Rehabilitation ¦ Volume 3 ¦ Issue 2 ¦ July-December 2018 79
Financial support and sponsorship
Nil.
Conflicts of interest
Therearenoconictsofinterest.
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