CASE REPORT |
https://doi.org/10.5005/jp-journals-10077-3311 |
Management of Complicated Crown-root Fractures Involving Permanent Maxillary Incisors in Children: Two Case Reports
1–4Department of Pediatric and Preventive Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India
Corresponding Author: Mallayya C Hiremath, Department of Pediatric and Preventive Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India, Phone: +91 9686793102, e-mail: drmallayyahiremath@gmail.com
Received: 22 May 2024; Accepted: 04 July 2024; Published on: 06 September 2024
ABSTRACT
Traumatic dental injuries (TDIs) are common in children and young adults, with maxillary incisors being most commonly affected. Crown-root fractures account for 5% of TDIs affecting permanent dentition. Management of these requires consideration of endodontic, periodontal, and restorative factors. Various treatment options are available that need to be chosen based on the clinical scenario. This article reports two cases of crown-root fractures in children, which were managed using a multidisciplinary approach. The two major challenges faced during the treatment were salivary contamination during endodontic treatment and subgingival fracture margins. These challenges were successfully managed, and the remaining tooth structure was preserved, which maintained the alveolar bone height around the area and prevented malalignment of the adjacent teeth. This also helped in the psychological and social well-being of the child.
How to cite this article: Hiremath MC, Krishnappa S, Kamath VK, et al. Management of Complicated Crown-root Fractures Involving Permanent Maxillary Incisors in Children: Two Case Reports. J South Asian Assoc Pediatr Dent 2024;7(2):117–122.
Keywords: Case report, Crown-root fracture, Gingivoplasty, Orthodontic extrusion, Post crown
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained writteninformed consent from the patient’s parents/legal guardians forpublication of the case report details and related images.
INTRODUCTION
Traumatic dental injuries (TDIs) affect 25% of school children, with most injuries occurring before the age of 19 years.1 Children who suffer from facial trauma resulting in missing, dislocated, or fractured teeth may experience functional, esthetic, and psychological consequences.2,3 The most commonly involved tooth is the maxillary central incisor affecting 80–83% of TDI.4 Self-fall being the major cause.5 Crown-root fracture is defined as a fracture involving enamel, dentin, and cementum, further divided into two categories based on pulpal involvement—uncomplicated and complicated.6 They constitute 5% of TDIs affecting the permanent dentition and 2% in the primary dentition.5 They are challenging to handle, requiring consideration of endodontic, periodontal, and restorative factors.2,7
CASE DESCRIPTION
Case 1
An 11-year-old boy presented to the Department of Pediatric Dentistry with a history of trauma to the anterior tooth region due to a self-fall. The medical history was noncontributory. Clinical examination revealed an oblique fracture on the labial surface of tooth 21 that exposed the pulp chamber and extended palatally 3.5 mm below the gingival margin (Figs 1A and B). The coronal fragment of the tooth was not retrieved by the attendant. After obtaining the parents’ consent, root canal therapy was performed on tooth 21 and obturated with gutta-percha (Dia Dent, Korea) (Figs 1C and D). To increase the crown-root ratio, it was decided to extrude the tooth orthodontically using the McLaughlin, Bennett, and Trevisi (MBT) bracket system (Garmin, United Kingdom) with 0.022-inch slots, which were bonded to teeth 11, 12, and 22. The flap was raised using two vertical and one crevicular incision in relation to tooth 21 (Fig. 2A), following which an orthodontic button was bonded to it (Fig. 2B). A ligature wire was tied to the button, which was engaged to a 0.012 Nickel-Titanium (NiTi) wire (Garmin, United Kingdom) (Figs 2C and D). After 2 months, 4 mm of tooth structure was extruded. The appliance was retained for a period of 4 weeks.
Figs 1A to D: Case 1 images. (A) Clinical appearance of crown-root fracture of 21; (B) Radiographic appearance; (C and D) Endodontic procedure done with 21
Figs 2A to D: Case 1 images. (A) Flap elevation; (B) Bonding of orthodontic button; (C and D) Ligature wire tied to NiTi arch wire for orthodontic extrusion of 21
Coronal migration of gingiva due to orthodontic extrusion with respect to tooth 21 (Fig. 3A) was corrected using gingivoplasty (Fig. 3B), leaving 5 mm of supragingival tooth structure. After the healing of the gingival tissue, 4 mm of apical gutta-percha (Dia Dent, Korea) was retained, and cementation of the fiber post (GC, Japan) was completed. Core buildup was performed using a packable composite (Coltene, Switzerland) (Figs 3C and D). A temporary acrylic crown was fabricated and cemented using type-1 glass ionomer cement (GC, Japan) (Fig. 3E). Around 1-year follow-up evaluation shows satisfactory clinical and radiographic features (Figs 3F and G). The patient will be followed up periodically, and a permanent esthetic crown is recommended after the age of 18 years.
Figs 3A to G: Case 1 images. (A) Crown structure available after orthodontic extrusion of 21; (B) Gingivoplasty; (C and D) Post cementation and core buildup with 21; (E) Acrylic crown cementation with 21; (F) 1-year follow-up clinical image; (G) 1-year follow-up radiograph
Case 2
A 13-year-old boy reported to the Department of Pediatric Dentistry with a history of an alleged self-fall. The medical history was nonsignificant. Clinical examination showed a complicated crown-root fracture of teeth 11 and 21, with a fracture line running obliquely in a labiopalatal direction (Fig. 4). A mobile coronal tooth fragment was seen attached palatally to tooth 11, extending 4 mm subgingivally. After obtaining the parents’ consent, the mobile coronal fragment was extracted under local anesthesia (Becain ADR, India). After the placement of glass ionomer cement (GIC) type-2 (GC, Japan) palatally to prevent moisture contamination, root canal therapy was performed on teeth 11 and 21, and the canals were obturated with gutta-percha (DiaDent, Korea). Following this, the case was managed similarly to case 1. Fiber posts were cemented, composite resin core buildup was done, and porcelain-fused-to-metal (PFM) crowns were fabricated and cemented on teeth 11 and 21 using type-1 GIC (GC, Japan) (Figs 5 and 6). Around 1-year follow-up evaluation showed satisfactory clinical and radiographic outcomes (Figs 6F and G). The patient was recalled for periodic follow-up evaluations and was advised to have the PFM crown replaced after the age of 18 years.
Figs 4A to C: Case 2 images. (A and B) Clinical appearance of crown-root fracture with 11 and 21; (C) Radiographic appearance
Figs 5A to C: Case 2 images. (A) Flap elevation and bonding of orthodontic button; (B and C) Ligature wire tied to NiTi arch wire for orthodontic extrusion of 11 and 21
Figs 6A to G: Case 2 images. (A) Crown structure available after orthodontic extrusion; (B) Gingivoplasty; (C and D) Post cementation and core buildup in relation to 11 and 21; (E) PFM crown cementation with11 and 21; (F) 1-year follow-up radiograph; (G) 1-year follow-up clinical image
DISCUSSION
Instead of directly extracting an anterior tooth with complicated crown-root fractures extending subgingivally, dentists should try to preserve the tooth, as extraction can lead to alveolar bone loss in the area, compromising future treatments using implants, migration of adjacent teeth, and psychological stress.4 In the two cases reported here, if extraction had been performed, the patient would have had to wear a removable appliance until the age of 18 years, which could have increased the potential for plaque retention and caries risk in adjacent teeth.8 Managing complicated crown-root fractures after the removal of the fractured coronal fragment can be done by the following methods2,8:
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Restoration of the tooth if the fracture line has not encroached into the biological width.
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Supplement with gingivectomy and/or osteotomy to expose the fracture line in order to establish biological width prior to restoration.
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Initiation of endodontic treatment and restoration of the tooth with a postcrown, or orthodontic/surgical extrusion of the apical fragment followed by a postcrown.
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In severe cases, the tooth may be extracted and replaced with a prosthesis.
In both cases presented here, the fracture line extended subgingivally (3.5 mm in case 1 and 4 mm in case 2), encroaching on the biologic width. A gingivectomy/osteotomy would have compromised esthetics. Hence, a multidisciplinary approach was employed, where endodontic treatment was carried out after orthodontic extrusion, followed by restoration with a fiber post, composite resin core, and a crown. It may be difficult to manage teeth with crown-root fractures with endodontic therapy when the coronal fragment is removed, as this typically causes bleeding and gingival fluid contamination of the root canal.9 To avoid this, the palatal defect was restored with type-2 GIC (GC, Japan) up to the supragingival level. The GIC formed a continuous rim with the tooth prior to endodontic therapy, allowing the gingiva to heal without growing into the defect.9 The margin of the restoration should be supragingival or equigingival to allow for self-cleansing. The fracture lines in both cases extended subgingivally and encroached on the biological width. To position the margins at the intended gingival level, the apical fragments of the teeth were extruded. Due to the patient’s young age, orthodontic extrusion with mild forces was utilized to accomplish this procedure. The technique of sectional fixed orthodontics was employed, providing benefits such as easy access, minimal tooth structure needed for bracket placement, effortless cleaning, and good patient compliance. It takes longer than surgical extrusion, as the tooth must be retained in its new position for around four weeks to allow for the reorganization of the periodontal ligament prior to restoration.10,11
Orthodontic extrusion requires stretching the periodontal fibers without causing significant bone remodeling and can lead to inconsistency between adjacent gingival levels, which is undesirable.12,13 This was noted in both of our cases and was corrected with a gingivoplasty procedure. This helped achieve a sufficient crown-to-root ratio for restoring the crown structure. The post space was then prepared, retaining 4 mm of gutta-percha apically. A glass fiber post was cemented, followed by composite core buildup. An acrylic crown was placed in case 1, as the patient was 11 years old and in the late mixed dentition stage. The crown length of the permanent maxillary incisors can increase due to passive eruption until teenage completion.14,15 A PFM crown was placed in case 2, as the patient was 13 years old and in the permanent dentition stage, with all permanent teeth in good occlusion and a strong concern for esthetics. However, in both cases, it was recommended to replace the esthetic crowns after the patient reached the age of 18 years.
CONCLUSION
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Successful multidisciplinary management of complicated crown-root fractures involving permanent maxillary incisors in children is a challenging task for pediatric dentists.
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Proper restoration and preservation of the traumatized teeth allow for the maintenance of alveolar bone height, prevent malalignment of the adjacent teeth, and aid in the psychological and social well-being of the child.
ORCID
Mallayya C Hiremath https://orcid.org/0000-0003-1733-5432
Vaishnavi K Kamath https://orcid.org/0009-0009-0733-076X
Aditya S Naik https://orcid.org/0009-0005-2750-3817
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