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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 111-113

Forced orthodontic extrusion for anterior traumatized teeth by a simplistic approach


1 Department of Orthodontics, Endodontics and Periodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
3 Department of Orthodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India

Date of Web Publication18-Jun-2015

Correspondence Address:
Dr. Sameer Sidhagouda Patil
Sinhgad Dental College and Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-4696.159097

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  Abstract 

The management of patients with traumatic injuries to their dentition is an integral part of the general dental practice. Anterior teeth with fractures that extend subgingivally require a complex treatment plan that addresses biologic, esthetic, and functional factors, such as mastication and speech. Treatment of crown fractures often requires a multi-disciplinary approach. However, crown-root fractures with fracture line below the gingival attachment or alveolar bone crest present restorative difficulties. This case report presents a 24-year-old male who reported with fractured upper right lateral and central incisors and upper left central incisor following road traffic accident. On clinical examination, it was observed that the upper right lateral incisor had a horizontal fracture at the cervical one-third level with the fracture line extending subgingivally, mid crown fracture of right central incisor and incisal fracture of left central incisor. All the traumatized teeth were first treated endodontically, and then referred to our department for orthodontic extrusion before permanent crown placement.

Keywords: Anterior teeth, orthodontic extrusion, restorative difficulties, subgingival fracture, traumatic injuries


How to cite this article:
Patil SS, Panicker AS, Hindlekar A, Srinidhi S R, Dhumal A, Vhora K. Forced orthodontic extrusion for anterior traumatized teeth by a simplistic approach. J Dent Allied Sci 2014;3:111-3

How to cite this URL:
Patil SS, Panicker AS, Hindlekar A, Srinidhi S R, Dhumal A, Vhora K. Forced orthodontic extrusion for anterior traumatized teeth by a simplistic approach. J Dent Allied Sci [serial online] 2014 [cited 2019 Oct 23];3:111-3. Available from: http://www.jdas.in/text.asp?2014/3/2/111/159097


  Introduction Top


Traumatic injuries to the teeth in the esthetic region of the face pose a great challenge to the general as well as the restorative dentist. Since the gingival display of the upper anterior teeth contributes, the micro esthetics of the smile maintenance of this delicate contour is of prime importance. With the recent trend and attitude toward dental implants, extraction remains the common treatment modality. This, however, should be considered as the last option, and every attempt should be made to preserve and restore the natural tooth structure. Such treatment modalities involve a multi-disciplinary approach including endodontics, periodontal crown lengthening, and/or orthodontic extrusion followed by prosthetic rehabilitation. Periodontal crown lengthening involves the removal of supporting crestal alveolar bone while orthodontic intervention forcibly extrudes the tooth. Both are attempts to expose sufficient coronal tooth structure for proper prosthetic restoration. Crown lengthening procedures may expose excess of root and in turn, may compromise esthetic results that can be avoided by the use of orthodontic extrusion. [1],[2],[3],[4]

Different methods of orthodontic extrusion of fractured teeth have been reported in literature which basically includes two principal approaches namely:

  1. Using brackets and wires as part of fixed mechanotherapy.
  2. Extending a rigid wire across the teeth neighboring the fractured tooth and applying traction forces to the fractured tooth through this attachment.


Orthodontic extrusion is usually achieved with fixed appliances. During orthodontic treatment, 20-30 g of force is required for extrusion.

The purpose of this paper was to review this multi-disciplinary treatment approach and to present a case of traumatized maxillary central and lateral incisors tooth with subgingival fracture and its management maintaining the healthy periodontal tissue and alveolar bone.


  Case Report Top


A 24-year-old male patient was referred to the Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, with fractured upper right lateral and right and left central incisors following road traffic accident. Clinical examination showed horizontal cervical fracture of upper right lateral and mid crown fracture of central incisor (nos. 11, 12) and oblique incisal fracture with exposed pulp tissue of upper left central incisor (no. 21) [Figure 1].
Figure 1: (a) Preoperative condition. (b) Postroot canal treatment and oral prophylaxis (c) preoperative radiograph

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The fractured fragment of 12 attached to the soft tissue was subsequently removed.

With patient's consent, root canal therapy was carried out immediately on the same appointment, and orthodontic extrusion was planned subsequently in the Department of Orthodontics and Dentofacial Orthopedics, Sinhgad Dental College and Hospital. After the tooth was asymptomatic for a week, rapid orthodontic extrusion was carried out [Figure 2].
Figure 2: The intrusion appliance in place

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Extrusion was done using a round 19 gauge rigid stainless steel stabilizing with soldered blobs placed on the wire. Based on the depth of the palatal fracture line, it was planned to extrude the tooth to about 3-4 mm. vertical bends were given in the wire to prevent rotation of the wire and to attain a larger length of elastic thread for adequate force generation. The wire was bonded to adjacent teeth (right no. 13 to left no. 21 teeth) using the composite restorative material. Begg brackets were bonded on 21 and 22. An elastic thread was stretched between the Begg brackets and the wire so that the thread seats between the blobs to avoid slipping of the elastic thread. A force of 35 g was applied which was measured using a Dontrix gauge.

The elastic thread was changed every 15 days till the desired extrusion was obtained. The total extrusion was completed in 2 months. After the stabilization period, definitive coronal restoration was planned. After the stabilization period, crown lengthening was performed to restore the gingival contours [Figure 3].
Figure 3: After extrusion and crown lengthening

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At this point, the remaining coronal structure was assessed, and it was judged to be adequate to retain a definitive full coverage restoration without any need for intra-radicular support. A cast post was prepared, and definitive ceramic crowns were placed over 11, 12, and 21 [Figure 4].
Figure 4: (a) Preparation of cast post (b) placement of ceramic crowns

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Patient was reviewed for 6 months, and the treatment outcome was stable and symptomless.


  Discussion Top


Movement of a tooth by extrusion involves applying tractional forces in all regions of the periodontal ligament to stimulate marginal apposition of crestal bone. Because the gingival tissue is attached to the root by connective tissue, the gingiva follows the vertical movement of the root during the extrusion process. Similarly, the alveolus is attached to the root by the periodontal ligament and is in turn pulled along by the movement of the root. [5]

If the fracture line is positioned both below alveolar bone and gingival free margin, and if the length of the root segment is sufficient enough to support a coronal restoration, then the root can be endodontically treated and afterward, orthodontically extruded to elevate the fracture plane above the gingival margin. These procedures enable more favorable prosthodontic coronal restoration by securing its good sealing and esthetics, and moreover, preserving a good periodontal tissue health. [6]

Forces of 15 g for the fine root of a lower incisor and 60 g for a molar are sufficient for slow extrusion. Some authors recommend that the maximum force for a slow movement should not exceed 30 g, [7],[8] whereas rapid extrusions are accomplished with forces higher than 50 g. [9]

Rapid orthodontic extrusion is carried out at higher forces; hence, longer retention periods are required to stabilize the tooth for remodeling and adaptation of the periodontium to the newly acquired tooth position.

Ulusoy et al. [10] and Fidel et al. [11] described a technique for extrusion using bonded brackets on the adjacent teeth.

However, with bonded brackets, there is a necessity to align the anteriors and time will be lost as a result. Furthermore, reciprocal forces of intrusion might act on the adjacent teeth.

Murali et al. [12] suggested a lingual technique using STB brackets. The same forces of intrusion are evident here.

Heda et al. [13] also suggested a similar technique using a bonded stainless steel wire. However, since no vertical steps were given for the extrusion, rolling of the wire was an issue.

In the technique used for this case, vertical steps were given to prevent the rolling of the wire. Furthermore, no need for aligning the anteriors since the rigid wire could be bonded directly chair side. Readily available and cheap Begg brackets were used as attachments. Furthermore, the technique is so simple that even the general dentist can perform this procedure.


  Conclusion Top


A multi-disciplinary approach is necessary for the restoration of tooth fractured at a subgingival level because the margin of restoration should ideally be supragingival. In this clinical report, a treatment modality for forced eruption therapy that minimizes treatment time and increases ease of use was described. The use of this technique for forced eruption may help the general dentist to have a better esthetic result and better patient appreciation.

 
  References Top

1.
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. 1
    
2.
Johnson RH. Lengthening clinical crowns. J Am Dent Assoc 1990;121:473-6.  Back to cited text no. 2
    
3.
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. 3
    
4.
Fournier A. Orthodontic management of subgingivally fractured teeth. J Clin Orthod 1981;15:502-3.  Back to cited text no. 4
    
5.
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. 5
    
6.
Bielicka B, Bartkowiak M, Urban E, Tomasz M. Holistic approach in the management of subgingivally fractured premolar tooth: Case report. Dent Med Probl 2008;45:211-4.  Back to cited text no. 6
    
7.
Minsk L. Orthodontic tooth extrusion as an adjunct to periodontal therapy. Compend Contin Educ Dent 2000;21:768-70.  Back to cited text no. 7
    
8.
Reitan K. Clinical and histologic observations on tooth movement during and after orthodontic treatment. Am J Orthod 1967;53:721-45.  Back to cited text no. 8
    
9.
Bondemark L, Kurol J, Hallonsten AL, Andreasen JO. Attractive magnets for orthodontic extrusion of crown-root fractured teeth. Am J Orthod Dentofacial Orthop 1997;112:187-93.  Back to cited text no. 9
    
10.
Ulusoy A. Indirect composite restoration of a crown fracture. J Dent Child 2012;79:2.  Back to cited text no. 10
    
11.
Fidel SR, Fidel-Junior RA, Sassone LM, Murad CF, Fidel RA. Clinical management of a complicated crown-root fracture: A case report. Braz Dent J 2011;22:258-62.  Back to cited text no. 11
    
12.
Murali RV, Rajashekhar L, Rajalingam S. Extrusion of fractured anterior tooth - An invisible approach. Indian J Multidiscip Dent 2011;1.  Back to cited text no. 12
    
13.
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. 13
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