Australian Dental Journal 1998;43:(1):28-31
Combined endodontic-orthodontic and prosthodontic
treatment of fractured teeth. Case report
.
Ilken Kocadereli, DDS, PhD*
Fügen Tas, man, DDS†
Sibel Bas, han Güner, DDS, PhD‡
Abstract
A case history of a 10 year old patient who
accidentally injured his maxillary left central incisor
is presented. The fracture of the crown extended
about 4 mm below the crest of the alveolar bone.
After pulpectomy and root canal therapy, a screw
was cemented into the canal of the incisor. By
means of a removable orthodontic appliance, the
fractured tooth was extruded and the fracture line
was brought above the level of the alveolar bone.
The tooth was then restored with a veneer crown
over a post core.
A tooth that would have been extracted routinely
was thus saved and restored through the use of a
collaborative approach.
Key words: Combined endodontic-orthodontic, prostho-
dontic treatment, tooth fracture, case report.
(Received for publication September 1994. Accepted
December 1994.)
Introduction
Fracture of a tooth below the gingival attachment
or crest of the alveolar bone presents a very difficult
restorative problem. Such fractured teeth are often
considered hopeless and are extracted. Crown
lengthening procedures (electrosurgery of the
gi n gi val margins or periodontal surgery) are
attempted in some cases. The use of orthodontic
extrusion, also referred to as forced eruption, has
been suggested as an alternative to periodontal
crown lengthening which involves the removal of
supporting alveolar bone and can compromise
aesthetics.1-6
Extrusion is the easiest orthodontic movement to
achieve because it closely resembles natural tooth
*Research Assistant, Department of Orthodontics, Hacettepe
University, Ankara.
†Research Assistant, Department of Endodontics, Hacettepe
University, Ankara.
‡Department of Prosthodontics, Ankara Hospital, Ankara.
28
eruption. Only 0.2-0.3 N of force is required for the
forced eruption of a single rooted tooth.7 The speed
of extrusion is important. In slow extrusion the
alveolar bone surrounding the root moves with the
tooth. Biologic width realignment is then required to
obtain proper contour of the gingiva and crestal
bone. 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.8
Forced eruption is usually limited to one, two or
three maxillary anterior teeth or premolars with as
much as 5 mm of extrusion possible.9 Various splint
and modified Hawley appliances5,10 have been
proposed for orthodontic forced eruption.
Case report
A 10 year old boy came to the dental clinic 20
hours after he had fallen and injured his anterior
teeth. Clinical examination showed lacerations of
the upper lip with moderate oedema. The maxillary
left central incisor had a transverse fracture of the
crown and the maxillary right central incisor and left
lateral incisor also had fractures of their crowns. The
apices of the central incisors were nearly completely
formed. Radiographic examination verified the
presence of the fracture of the maxillary left central
incisor (Fig. 1).
The mobile crown portion was removed (Fig. 2,
3). The remaining portion of the tooth (the root
portion) was below the alveolar crest (Fig. 4). Root
canal therapy was carried out immediately to the
maxillary left lateral incisor. A root canal filling was
performed on the maxillary left central incisor.
Calcium hydroxide dressings were placed in the
maxillary right central incisor and left lateral incisor
as apical root formation was not yet complete. It was
decided to extrude the tooth orthodontically. A
screw post was cemented to the fractured tooth (Fig.
Australian Dental Journal 1998;43:1.
 1 2

Fig. 1.–Fracture of maxillary left central incisor (arrow).

Fig. 2.–Intraoral view after removal of crown portion of maxillary
central incisor.
Fig. 3.–Crown portion of maxillary left central incisor.
Fig. 4.–Root portion below the alveolar crest.

4). Elastic thread was applied from the screw post to
the specially designed vestibular arc of the Hawley
appliance for the extrusion of the tooth (Fig. 5, 6).
The patient was examined every four days to
check and reactivate the elastic thread. The child fell
down for the second time during active orthodontic
treatment and fractured his maxillary left lateral
incisor which had earlier been filled with calcium
hydroxide. There was clear evidence, both clinically
and radiographically, of about 5 mm extrusion of the
tooth (Fig. 7). Approximately six weeks later the
active treatment was ended. There were no
complications during or after the orthodontic treat-
ment. After completion of the extrusion, a post core
was performed (Fig. 8). The tooth was successfully
Australian Dental Journal 1998;43:1.
restored with a veneer crown constructed over the
post core. The fractured incisal portion of the right
central incisor was restored with a composite resin
using the acid etch method. The fractured maxillary
left lateral incisor was restored with a jacket crown
(Fig. 9, 10).
The patient was examined two years after treat-
ment. The stability of the crowns can be seen
clinically and radiographically in Figs. 11 and 12.
Conclusion
The necessity for an interdisciplinary approach to
treatments of routine dental problems has been
recognized for a long time. In the case described, an
29
 6

Fig. 5.–Periapical radiograph showing appliance and screw.

Fig. 6.–Elastic thread applied from screw post to appliance.
Fig. 7.–Extruded root portion.
Fig. 8.–Post core in the mouth.

endodontist, an orthodontist, and a prosthodontist References

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left central incisor. It is clear that without such
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been good.
In many cases, forced orthodontic eruption
provides a useful alternative to extraction or
extensive periodontal surgery. Adjacent teeth need
not be prepared for fixed prostheses and alveolar
bone is conserved.
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30 Australian Dental Journal 1998;43:1.

 9

10

11

Fig. 9.–Prosthetically restored maxillary left central and lateral incisors.

Fig. 10.–Periapical radiograph at end of treatment.
Fig. 11.–Intraoral frontal view two years after treatment.
Fig. 12.–Periapical radiograph two years after treatment.

12

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Australian Dental Journal 1998;43:1. 31