Interdisciplinary Management of Teeth With a Complicated Crown Fracture: A Case Report With Follow-Up Checklist

Abstract

Traumatic injuries resulting in damage to the teeth and associated structures have a grave psychological impact on the patient and hence, these require timely intervention. The fracture extent determines the appropriate treatment plan for the patient. Crown fractures can be treated aesthetically without the invasion of the biological width with meticulous interdisciplinary management. The objective of this article is to report a case of a 27-year-old Indian male patient who presented to our hospital the following day, post-trauma to the anterior teeth. On clinical examination, two teeth were found to have undergone fracture that involved the pulp chamber. Considering the overall oral health, pulpal and periodontal health, availability of the fragments, and invasion of the biological width, a tailor-made treatment plan was devised. The fractured crown fragments were reattached surgically, using a glass fiber post that resulted in an aesthetic biological restoration. This treatment has been successfully managed by an interdisciplinary approach. At the 18th-month follow-up, clinical and radiological examinations suggest a successful outcome.

Keywords: biomimetic dentistry; crown fracture; dental trauma; gingival recession; intraradicular splint.

Figure 1. Pre-operative images, surgical intervention steps and post-surgical steps.

(A) Arrows pointing at the horizontal fracture line with 21-22. (B1, B2) Pre-operative CBCT images in sagittal section showing oblique fracture line extending palate-cervically. It can be seen that the fracture line is extending supra-crestally and there is no concomitant root fracture. (C) Extraction of fragments using forceps. (D1-D3) Extracted fragment with removal of pulp in-toto; extracted fragments stored in saline; Preparation of a vent hole in fragment. (E) Palatal view after extraction of the fragments. Note the fracture site of the fragments seen horizontally on crown of each tooth. (F) Muco-periosteal flap raised from 11 to 22. Note that the root canal opening is closed and isolated using Teflon tape to prevent contamination of the root canals. Also note the controlled bleeding seen at the surgical site that has been achieved using gel foam. (G) Vertical mattress sutures placed using 3-0 vicryl sutures seen in labial view. (H) Vertical mattress sutures placed using 3-0 vicryl sutures seen in labial view. (I) Ribbond splint extending palatally from 21 to 23 to stabilize the teeth and prevent drifting away from each other.

Figure 2. Follow-up clinical and radiographic images (ninth-month follow-up clinical images; 18th-month follow-up radiographic images).

(A) Ninth-month clinical follow-up picture from labial view showing gingival papillary recession. (B) Gingival papillary recession between 21 and 22 has led to the formation of a gingival black triangle that is marked as seen in the image. (C) The shade selection is done using the VitaTM shade guide. The shade selected was A2. (D) Aesthetic composite splinting was done with composite restorative resin with respect to the inciso-proximal region of 21-22. (E) Three-month follow-up RVG showing intact tooth-fragment interface and absence of voids in the root canal suggesting the absence of any chance of microleakage development. (F) Nine-month follow-up RVG. (G) 18-month follow-up CBCT from sagittal and coronal view showing the maintenance of the intact tooth-fragment interface and absence of any periapical lesions.

Figure 3. The PRICE 2020 flowchart showing the steps involved in the case report.

For further details visit: http://pride-endodonticguidelines.org/price/ accessed on April 22, 2021. CBCT: Cone beam computed tomography