A common form of dental trauma is the fracture of anterior teeth, especially maxillary incisors because of their position in the arch. These types of traumatic injuries are more common in children and young adults. Aesthetic rehabilitation of traumatic injuries of the teeth and related structures is often complex requiring a multidisciplinary approach for a successful treatment outcome. There are multiple factors which will impact the management of a crown fracture. Some of the considerations include the extent of the fracture, biological width violation, endodontic involvement, occlusion, esthetics, secondary soft tissue trauma, and alveolar fracture. When the fracture extends below the gingival attachment or crest of the alveolar bone, it creates a complicated restorative problem. The distance from the alveolar crest to the restorative margin should be at least 3-4 mm to avoid impingement of the biologic width for optimal periodontal health. In cases where the fracture violates the biologic width, additional restorative options must be considered including forced eruption (orthodontic extrusion) and/or crown lengthening to reestablish the appropriate 3-4 mm of biologic width for optimal periodontal health. This case report describes the multidisciplinary management of subgingival horizontal crown-root fracture of permanent maxillary incisors.
A 25-year-old patient was involved in an out-of-state car accident sustaining fractures to teeth 7-10 (Figs. 1-3). She presented to our office two days post-accident for evaluation. No history of allergy or systemic problems was reported and the family history was also non-contributory. Extra oral examination revealed bruising and minor lacerations of the soft tissues of the cheeks and lips which had been treated at the emergency room. Intraoral examination revealed no lacerations of gingival tissue or evidence of alveolar fracture. Fracture was noted to both central incisors involving the enamel, dentin, and pulp. The margin of the fractures on both 8 and 9 was clinically visible on the labial side, but not on the palatal side (Fig. 4). Radiographic findings revealed an oblique fracture of both 8 and 9 extending subgingivally below the gingival attachment to the osseous crest. The radiographs also revealed altered passive eruption in which some of the clinical crowns of the anterior teeth had failed to fully erupt. Initially, the patient was referred for emergency endodontic treatment of 8 and 9 with post spaces prepared for the future restorative treatment.
Following endodontic treatment, the patient returned for a records appointment in which a full series of radiographs, impressions, a facebow, and a centric relation bite registration were obtained. Composite restorations were temporarily placed on the incisors 7-10 to determine the ideal incisal edge position as well as temporarily restore the patient’s front teeth (Fig. 5). An impression of the composite mock up was taken for the lab to use as a guide when ordering the diagnostic waxup. The evaluation also included periodontal charting, temporomandibular joint (TMJ) exam, occlusion evaluation, and the AACD photographic series. The study models were mounted on a Denar articulator.Analysis of her smile showed excessive gingival hyperplasia, low frenum attachment between the central incisors, worn incisal edges of canines, lack of canine guidance, and insufficiently developed buccal corridor. In addition to restoring the fractured teeth, the patient’s concerns also included changing the appearance of her “gummy smile and small teeth”.The esthetic challenges were discussed with the patient along with various treatment options and consent was obtained for the treatment chosen. The patient elected anterior crown lengthening of 4-13 along with a combination of crowns and laminate veneers for teeth 4-13 and 22-27. The patient was referred to a periodontist for evaluation of the subgingival fractures of teeth 8 and 9, and for esthetic crown lengthening of the other maxillary teeth.
A diagnostic wax-up was fabricated in which proper canine guidance was reestablished along with ideal height to width ratios in anticipation of the final gingival position following crown lengthening of 4-13. The patient reviewed and approved the diagnostic wax-up.Putty matrices were fabricated to check for appropriate reduction during the preparation phase in addition to provisionalization. Vacuum-formed surgical stents were fabricated as a guide for the treating periodontist for the anterior crown lengthening. The patient was referred back to the periodontist for a frenectomy between 8 and 9 along with crown lengthening of teeth 4-13.
Tooth Preparation and Provisionalization
Following the initial healing phase post crown lengthening, the prior composites on 7-10 were removed. Teeth 8 and 9 were accessed from the lingual for placement of composite fiber posts and core buildups then prepared for full coverage crowns. Teeth 4-7, 10-13, and 22-27 were prepared for veneers using the matrices generated from the diagnostic wax-up to ensure appropriate reduction in all dimensions. Provisionals were fabricated by filling the putty matrices of the diagnostic wax-up using Luxatemp. The provisionals were trimmed and cemented using a combination of Tempbond Clear for 8 and 9, while the veneer temporaries were placed using the “spot etch/bond” technique. The patient was asked to wear the provisionals for an additional four weeks for continued soft tissue healing. This also allowed us to “test” the esthetics and function of the provisional restorations.
The patient returned a month later for follow-up. Overall, she was pleased with the appearance of the provisionals and reported no functional issues. Some minor modifications were made with the provisionals and new impressions were taken for the lab to follow as a guide when fabricating the final restorations. The patient was then anesthetized and the provisionals were removed. A double-cord technique was used for the final impressions. A new facebow record and bite registrations were obtained. Stump shade photos were taken for the laboratory. Her provisionals were remade from a new putty matrix created after the minor modifications of the original provisionals, trimmed, and cemented in the same manner as previously described. Shade selection options were discussed with the patient and she selected Vita 3D shade OM1 body with incisal translucency. Material selection was later discussed with the ceramist and we decided on IPS Emax Press restorations in order to layer in the incisal edge translucency.
Delivery and Cementation
The patient returned a month later to try in the final ceramic restorations.In order to adequately evaluate the restorations, no anesthetic was used initially. The provisionals were removed, the preparations were cleaned, with flour pumice, and the Emax restorations were placed with translucent try-in paste. The patient was very pleased with the esthetics and consented to final cementation. The restorations were cleaned and silinated. The patient was then anesthetized prior to cementation. The preparations were then isolated and treated with etchant, All Bond Universal, followed by cementation using Variolink II Dual Cure translucent resin cement. Oxygen-inhibiting glycerin gel was applied at the margins with final light curing. The patient returned a week later for the final photographic series and to recheck occlusion (Figs. 6-9).
Routine dental problems often require an interdisciplinary approach for a successful outcome. The best possible results require careful evaluation of the case with the treatment modality focused toward the outcome in terms of function and esthetics. Without a team approach, the functional and esthetic results would have been significantly compromised. In this case, the collaboration of an endodontist, a periodontist, a restoring dentist, and a ceramist were essential in accomplishing the treatment goals of this case.
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About The Author
Carleigh M. Prane received her degree from Southern Illinois School of Dental Medicine in 2002 while concurrently
receiving a full Naval scholarship. After graduating with honors, she completed an Advanced Education in General Dentistry residency program at Pensacola Naval Air Station. She began in private practice in O Fallon, IL in 2006. She participates in numerous continuing education courses and maintains active membership in the following dental organizations: American Dental Association, Academy of General Dentistry, American Academy of Cosmetic Dentistry, American Academy of Dental Sleep Medicine (AADSM), Illinois Dental Association, Missouri Dental Association, St. Clair Dental Society.